“During my last visit to my homeland, I sensed a new spirit, a spirit of progress and awakening that made me proud of my citizenship, and the conference I am currently attending sets a fine example for this awakening.”Footnote 1 This testimony was given by a Palestinian who visited his homeland after three decades in the diaspora. The conference he mentioned was the first Congress of Arab Doctors in Palestine, convened in Haifa in June 1933. Thirty-five physicians attended, over one-third from Haifa, alongside representatives from Jaffa, Jerusalem, Safed, Tulkarm, Shafa ‘Amr, Nablus, and Nazareth. A similar number of doctors who could not attend had sent letters of empowerment to the delegates, bringing the total number of delegates and supporters to seventy-five. It would have been impossible to imagine an event such as this thirty years earlier, when the anonymous attendee had left Palestine. Moreover, the challenges and demands faced by this community could have hardly been imagined at the turn of the century.
The small community of Arabic-speaking, university-trained doctors numbered roughly twenty on the eve of World War I, but expanded more than tenfold by the end of the British Mandate in 1948. The present study historicizes this community of Palestinian doctors by tracing their sociocultural background, training, and modus operandi under British colonialism; their acculturation to professional, institutional, and political life in Palestine; and their engagement with the Zionist challenge. The research questions to be considered are: How was Palestine able to produce a large professional medical community, even in the absence of medical schools? How did education abroad affect this community? How did the colonial and settler-colonial contexts affect the formation of the profession? When and how did Palestinian doctors organize, and what does this tell us about Palestinian sociopolitical mobilization? We then analyze this professional community in the context of the emergence of professions under colonialism.
We argue that this professional community's evolution provides a unique case study in the history of professions under colonialism. Moreover, although the historical circumstances of Mandate Palestine provide the rationale for this uniqueness, the proposed model of analysis challenges the prism through which we see the evolution of professions under colonialism, especially its emphasis on the role of the colonizer rather than the colonized. From its inception in the late Ottoman period, Palestine's medical community expanded independently, despite and not because of British rule. Its growth did not depend on British financial support for training in medical schools abroad, nor was the government the sole employer of certified doctors. Following historians of medical professional communities in other colonial settings, we argue that this expansion was usually a product of local will and potential backed by cultural and actual capital.
Yet therein lay the challenge for the community. Characterized by decentralization and mostly individual rather than collective agency, association and institutionalization were a challenging undertaking. Unlike many other colonial societies, Palestinian doctors also struggled against or worked alongside a large settler community, a set of interactions that shaped the Palestinian doctors’ professional community. The Zionist project, especially since the 1930s, posed professional and occupational challenges, as Jewish doctors offered expanded medical services to the Arab population.
Since our sources contain multiple fragments of information about hundreds of individuals, we rely partly on collective biography, a combined study of doctors’ lives and careers.Footnote 2 We examine their social origins and inherited political and economic position; training paths; place in the colonial system; and ability to mobilize for political action. Such a study enables us to examine social structure and mobility. Building on this profile, we argue that the uniqueness of this community lies in its diversity of sociopolitical functions, as its individuals act interchangeably as loyal colonial civil servants and associates of their Jewish colleagues or as ardent anti-Zionist and anticolonial nationalists.
Though some works have explored the history of labor in Mandate Palestine, particularly in relation to the Jewish settler community, scholarship on Mandate Palestine is only beginning investigation of local histories of professions, and Palestinian doctors have never been studied as a professional community.Footnote 3 Histories of medicine in the Mandate period focus mainly on health services, or alternatively on Jewish medical services and personnel. Works on the history of public health highlight the unequal development of the Jewish and Arab health services, due to neglect on the part of the Mandate authorities as well as imbalance between Jewish and Palestinian Arab medical infrastructure and personnel.Footnote 4 As in other domains, we see a state-building process on the Jewish side, reluctance of Mandate authorities to invest in the Palestinian Muslim and Christian population's welfare, and the challenges facing Palestinians as they attempt to build state-like institutions or force the Mandate authorities to do so.Footnote 5
Scholarship on medicine in Mandate Palestine, moreover, marginalizes Arab doctors relative to the missionary infrastructure and subsequently relative to the large community of Jewish doctors.Footnote 6 This historiography tends to reduce Palestinian doctors to their hostility to the Zionist project and their inferior medical training when compared to their Jewish counterparts. Allegedly preferring profit to national commitment, they are usually presented as the main culprits in the poor medical infrastructure on the Arab side and particularly the collapse of medical services during the 1948 war.Footnote 7 A community of only a few hundred, supposedly falling short as the backbone of a national urban middle class, they have been of very little interest to historians.Footnote 8
Another reason for the marginalization or erasure of Palestinian doctors has been the almost exclusive reliance on official colonial documents.Footnote 9 The present study addresses this gap by closely reading documents from the Israel State Archives (ISA) as well as the Palestinian press and doctors’ memoirs and publications. These sources enable us to tell their stories in the broader regional and Arab context and to introduce their relationship with their Jewish counterparts within the context of their world.
Looking beyond the study of the history of medicine in the region, this article is a part of a larger endeavor to reconstruct the Palestinian professional middle class. It follows, for example, Sherene Seikaly's project of liberating the Palestinian historiography from its narrow focus on “the Aristocrat, the Comprador, the Hero, and the Catastrophe,” often surveyed as two-dimensional emblems of culture and class, turning into relevant actors only for their roles in relevant (national) history.Footnote 10 We also follow Keith Watenpaugh's interest in a middle class born out of late Ottoman historical processes, whose members’ education and professional training supplemented or intersected with lineage and belonging to the urban nobility to define their identity.Footnote 11 As Toufoul Abou-Hodeib demonstrates, new tastes and manners, as well as a corpus of ideas and practices, helped them distinguish themselves from both the a‘y ān and the subaltern urban and rural poor.Footnote 12 Still, with the longest and most selective and demanding academic career, doctors were exceptional even within this group. The nature of their training and humanistic vocation prompted the creation of professional networks that challenged postwar borders, making this community unique in the study of middle class identity and formation.
This article builds on and contributes to a sociological and historical exploration of the emergence of the professions in colonial and postcolonial societies. As we will show, historians of colonial societies have challenged the sociological disregard for race and ethnicity. Sociologists of professions tend to conceptualize them as interrelations between universities, the state, users, and professional associations.Footnote 13 Adjustment of this model to colonial and postcolonial cases, by contrast, takes into account power structures between colonizer and the colonized, as well as within colonized society itself, that facilitate or restrict the formation of professional communities. The Palestinian case study presents yet another model, in which limited educational opportunities in Palestine as well as fierce professional competition with Jewish professionals shaped the emergence of the profession. The accountability of the colonial state toward its users—patients in this context—is also a part of the equation. As for a national professional association, it was late to develop and was in constant competition with that of the large and prosperous community of Jewish doctors.
CONCEPTUALIZING THE PROFESSIONS
In their 1990 chapter, Michael Burrage, Konrad Jarausch, and Hannes Siegrist formulated a conceptual framework for a comparative study of the professions as an interaction between the university, the state, individual users, and professionals and their associations. These four categories of actors and their interactions, they argued, can help us understand the resources at the disposal of a professional community and its historical development.Footnote 14
Universities, in this model, train professionals and provide them with the cultural and practical capital on which their status and practice depend.Footnote 15 Education forms group identities and bonds among those who participate in the same schooling rituals. University graduates thus form a status group, as described by Randall Collins: a network of people who perform interaction rituals among themselves and arrive at a common conception of identity, purpose, and honor status.Footnote 16
Second, states provide licensing, regulate professional life, and are instrumental in professional advancement. They are involved in the organization of the profession, are major employment providers, regulate the relationship between this profession and neighboring ones, and usually regulate education as well. States have a vested strategic interest in providing resources and in employing the resources that the profession can provide.Footnote 17
The third category in the model is users. Their material resources and demand for professional services have a crucial role in the development of the profession. Initially in demand mainly by the elite, professional services gradually become available to the middle class and later to larger parts of the population. Medical insurance and state-sponsored health services expand demand, and with it the user community.Footnote 18
Finally, the fourth category comprises the medical professionals themselves and their ability to unionize, self-regulate, and project and enhance their collective interest in relation to the other three actors. They are responsible for the profession's cohesion and continuity by the creation of mechanisms of formal and informal socialization. Such frameworks provide continued dissemination of knowledge and advocacy for the profession.Footnote 19
Historians of the professions in colonial societies challenge the validity of this theorization, as it overlooks gender, race, ethnicity, and power relations outside the professional field. They demonstrate, instead, how central race, ethnicity, and colonial power relations are to the formation of professions under colonialism as well as to the formation of professional as well as national or ethnic identities. Rendering the professions historically with accuracy entails examining interactions between the profession, ethnicity, and civil society. In her work on the Taiwanese medical profession under Japanese rule, for example, sociologist Ming-Cheng M. Lo demonstrated that doctors’ pursuit of market interests was qualified by ethnic solidarity with their consumers and that their organizational autonomy served both to protect their professional market and to assist in the anticolonial struggle. She suggests studying the emergence of professions under colonial rule by examining, first, the profession's internal organization and its knowledge base, cultural system, and group interests; second, ethnic networks within the colonized society, their cultural traditions, and structural inequalities between the colonizer and the colonized; and finally the context of the colonial state and colonized civil society.Footnote 20
In colonial contexts (largely ignored by sociological models) education was designed to create a cadre of intermediaries between the colonial power and the indigenous population. University graduates were integrated into the lower ranks of the colonial administration. Universities in colonized societies were rare, and those that did exist attracted students from neighboring colonies and facilitated the formation of group identities that crossed colonial frontiers as well as a trans-imperial circulation of ideas, models, and experiences. Such experience allowed colonized students studying abroad to form links with others sharing a common purpose, culture, and identity and to develop social ties and networks beyond the colony. The establishment of universities in the colonies, moreover, was sometimes designed specifically to prevent local students from traveling abroad and integrating into anticolonial networks. From the onset, then, university education created racial distinctions that limited professional mobility and the salary scale of the colonized professional.Footnote 21
Professionals in colonial contexts therefore stood outside the sociological race-blind model and involved national, racial, or ethnic power relations that affected, for example, patients’ trust of biomedicine, and the glass ceiling limiting promotional tracks of colonized professionals within the government. Like many other university graduates, doctors often played key roles in both the anticolonial movement and the colonial administration. In West Africa, for example, African doctors had a difficult time finding employment outside the government in the late 19th century, because few African patients trusted Western biomedicine. They could do better with the colonial medical service, but at the expense of sacrificing their professional autonomy and serving as the arm of the state among the colonized. Within government service, they faced lower status even when they studied in the same metropolitan universities as their British counterparts. Such tensions led some of them to withdraw from the colonial medical services. In the early 20th century, by contrast, private practitioners benefited from the emergence of an African elite, willing to consult Western medicine. This process allowed them greater professional autonomy.Footnote 22 Finally, in the case of Japanese-colonized Taiwan, positions within the colonial administration served as a form of co-optation of local elites.Footnote 23
Doctors’ roles in anticolonial movements can also be ascribed to their social position within their respective societies. In the case of Taiwan, medicine was one of the only venues for upward social mobility. Whereas the old elites were composed mainly of landowners and the gentry, with status based on inheritance, the medical profession enabled non-elites to gain social status, prestige, and capital. Since medicine entailed a long course of study, sometimes abroad, most doctors hailed from the elites, and relied not only on their education but also on their family background for social prestige. Thus, in practice, emergence of the new educated elites caused little disruption for the old.Footnote 24 In West Africa, as well, medicine was one of the few professions that provided Africans with independence and class mobility.Footnote 25
Our analysis considers the colonial critique in the Palestinian context. We show, first, that Palestinian doctors originated mostly from well-established families, supplementing older capital (be it based on religious education or landownership) with new educational and professional capital. At the same time, education allowed a limited number of newcomers into the field. Second, in the case of the American University of Beirut (AUB), where most Palestinian doctors studied medicine, university education outside of Palestine incorporated our protagonists into regional and transnational networks—which also posed a threat to the colonial state. As in other colonial contexts, the Mandate authorities placed British medical officers at the top of the administrative hierarchy and thus blocked both the autonomy and career prospects of the Palestinian medical profession. The limited resources of Palestinian society meant a limited pool of private patients, which made the Mandate administration a more viable employment opportunity. Within the medical profession, moreover, there were tensions with and struggles against the growing Jewish medical profession and Zionist medical institutions. Thus, to the colonial dyad of colonizer and colonized, we must add the settler-colonial element: competition with Jewish doctors was crucial to the development and reconceptualization of the Palestinian Arab medical profession.
EDUCATION AND SOCIAL MOBILITY
Since late Ottoman and Mandate Palestine offered no higher education for its Arab population, those pursuing higher degrees turned abroad, mainly to nearby Beirut, which offered two medical schools, at the Syrian Protestant College (SPC, established in 1866, later named AUB) and at St. Joseph University (established in 1883). Other options included the Imperial Medical School in Istanbul and Qasr al-‘Aini medical school in Cairo, both established in 1827, and the Damascus Faculty of Medicine (established in 1903).Footnote 26 The limited access to higher education made access to the profession class-specific and brought to the field mostly actors endowed with landowning or mercantile economic backgrounds. It also provided limited social mobility for non-elites who had access to missionary or public education. In addition, as will be seen, education outside Palestine provided valuable professional networks and pan-Arab, trans-imperial, and anticolonial experiences and exchanges.
The formation of a university-educated medical profession in Mandate Palestine had its roots in the last decades of the Ottoman Empire. Historian Kamal al-‘Asali noted a “first wave” of Palestinian doctors graduating around 1900: five men, three of whom graduated from SPC and two from the Imperial Medical School.Footnote 27 A second wave of fourteen doctors graduated around 1915.Footnote 28 According to Nissim Levi, at least nineteen Arab doctors from Palestine served in the Ottoman army during the war.Footnote 29
The available pool of medical students may be ascribed to the expansion of secondary education during the late Ottoman period: both missionary (in English, French, German, and Russian) and Ottoman (in Ottoman Turkish). Education at these schools provided language skills that prepared students for future medical training in English or French. Missionary education prepared students mainly for foreign medical faculties, both in Beirut and outside the Middle East; Ottoman education prepared students mainly for the Ottoman faculties in Istanbul and Damascus.Footnote 30
The Jerusalem missionary schools, especially the Protestant and Anglican, stand out as trainers of future doctors. In fact, some of the more senior medical officers of the Mandate years were products of these late Ottoman institutions. The son of a Protestant preacher, prolific intellectual and pioneering physician Tawfiq Kan‘an (1882–1954), born in Bayt Jala, south of Jerusalem, graduated from the teachers’ division (seminar, established in 1890) of the German Mission's Schneller School in Jerusalem, a diploma that enabled his enrollment at SPC in 1899.Footnote 31 More than a decade his junior, Futi Frayj (1895–1956), son of a Bethlehem carpenter, graduated from Schneller in 1913 and was hired as a teacher—a position that allowed him to save enough money to fund his medical degree at SPC shortly after the war.Footnote 32 Dr. ‘Izzat Tannus (1896–1969) mentions how natural it was for him to continue his education at SPC after graduating from St. George's since the language of instruction was English and the general ambience felt familiar.Footnote 33 Mission schools attracted students from notable Muslim families as well.Footnote 34 Venerated religious scholar Shaykh Raghib al-Khalidi, a member of Jerusalem's Ottoman education department, held Anglican education in the highest esteem. He sent three of his sons and future medical students Hassan Shukri (1893–1966), Husayn Fakhri (1894–1962), and Ahmad Samih (1896–1951) to the Anglican St. George's School in Jerusalem (established in 1899).Footnote 35
The Ottoman state schools offered another venue for professional mobility and prepared students for higher education in Istanbul or Damascus. Ottoman schools prepared young men for service in the growing Ottoman bureaucracy, but also disconnected them from customary patterns of education and from their communities and blurred the lines between religious sects.Footnote 36 Dr. Muhammad Hathat (1881–1931) from Gaza, for example, completed his elementary education in local Ottoman state schools, and proceeded to secondary education in the Ottoman Sultaniye High School (Mekteb-i Sultani) in Beirut. With his diploma from the Sultaniye, Hathat was able to enroll at the Imperial Medical School (Mektep -i Tibbiye-i Sahane) in Istanbul. Upon graduation, Hatat became a doctor-officer in the Ottoman army, defected, and then served as the personal doctor of Sharif Husayn.Footnote 37
Already in the late Ottoman period, SPC had become the main regional hub for medical education.Footnote 38 French historian Chantal Verdeil describes how, in the decades preceding the war, both SPC and St. Joseph's attracted students from the entire Eastern Mediterranean and beyond—from Anatolia, Egypt, the Levant, Iraq, and even Iran and the Balkans.Footnote 39
The postwar establishment of the British Mandate in Palestine made SPC, renamed AUB in 1920, even more attractive. The colonial department of education formulated the Palestine matriculation examination for a secondary school diploma in accordance with AUB's requirements. The strong personal relations between the heads of the colonial department and the Anglophone Protestant staff of AUB, as well as the fact that the department's leading officials had studied there, strengthened this connection. The Beirut faculties of medicine attracted particular graduates of missionary schools who had the language, training, and exposure to European curriculum that enabled them to pass the matriculation exams.Footnote 40 In the 1920–21 academic year, ninety-seven Arab and Jews from Palestine were enrolled at AUB. This was a small number in comparison to students from Beirut (348), but not in comparison to the forty-eight students from Aleppo and northern Syria or the twelve from Iraq.Footnote 41 In 1932–33, 240 students from Palestine studied at AUB, including about 148 Jews;Footnote 42 their number reached 336 in 1939.Footnote 43 According to Najib Qaranful, the percentage of Palestinians (presumably both Arab and Jews) graduating from AUB's School of Medicine between 1935 and 1949 was 17 percent, along with 15 percent Armenian doctors (many of whom ended up working in Palestine).Footnote 44 Educating hundreds of Palestinians throughout the Mandate period, AUB became among the most influential institutes of Palestine's educated elite.Footnote 45
Almost all of these students were men. Palestinian women joined the growing medical community mainly as nurses or qualified midwives. Missionary schools started training some of their graduates to work as nurses as early as the first decade of the 20th century. In 1905, SPC started a nursing program, which due to its language requirements was open only to graduates of English-speaking missionary schools. In 1919, the Mandate authorities required nurses to complete three-year training in one of Palestine's eighteen hospitals, and beginning in 1922 government hospitals offered six-month courses in midwifery. Most deliveries were still conducted by traditional midwives who lacked formal training (d āyāt). They too, however, had to register. Like Arab doctors, nurses typically occupied the lower ranks of hospital administration and were subordinate to British matrons.Footnote 46 Moreover, although AUB's schools of medicine, dentistry, and pharmacy were open to women in 1924, only a handful of female doctors graduated from them in the period under study: seven physicians and three dentists, including doctors Salwa Habib Khuri, Veronica Bakumijian, and Charlotte Saba and dentist Nahil Habub Dajani.Footnote 47
At AUB, students met peers from the entire region, and their shared language and common ground helped them form personal, political, and professional networks.Footnote 48 The intensive school days far from home not only turned them into an intimate group but also refined their ideological and national worldviews. Their clubs and extracurricular activities helped reinforce horizontal bonds along class lines, crossing religious and ethnic boundaries, and separated those middle class men (and few women) from both the notable elite and the urban poor.Footnote 49 Theater productions as well as the university's popular sports club were among the venues it offered for networking.
Dr. Ilyas Sruji, who graduated in 1944, for example, recalls his influential teachers at AUB and the activities of the Firmest Bond Society, the most popular group at the university, where speeches and debates about Arab nationalism were often held. According to Sruji, the Palestinian students were the most dominant group in the society.Footnote 50 Palestinian students were the second largest national group, and during the early 1920s a Palestinian Club was active at AUB. Da'ud al-Husayni, a dentistry student in the late 1920s, mentions the establishment of an imaginary state after the dissolution of the Palestinian Club, for which Palestinian students took “formal” positions. He and his roommate, future doctor Mahmud Tahir al-Dajani, were ministers of the interior, and Rif‘at Faris served as chief patriarch.Footnote 51
The influence and connections of the school did not end upon graduation. It remained a hub for all graduates, who kept visiting it and kept in touch with one another through its alumni societies, its journal al-Kulliya, and various conferences. Beginning in the early 1920s, graduates established local branches in Palestine.Footnote 52 The university also had its own Medical Society, which held meetings and professional lectures.Footnote 53 Through the medical conferences that began prior to World War I, it became an active network for doctors discussing contemporary medical issues and organized medical research lectures.Footnote 54 The university also hosted alumni reunions with symposiums on various medical topics, as well as visits to clinics and hospitals.Footnote 55
These regional and transnational networks, with their roots in the late Ottoman period, became a potential threat in the colonial era. In a different context, the establishment of the medical school in Baghdad in 1927 had the declared aim of realigning networks of medical authority within the British political orbit and distancing local practitioners from pan-Arab regional networks.Footnote 56 For similar reasons, the British considered on several occasions the establishment of a British university in Palestine that, unlike the Hebrew University in Jerusalem (established in 1925), would attract Arab students. Its curriculum was to be British rather than American (unlike AUB) and its “social and national ideal” would not be pan-Arabism, but rather “Palestinianism.” Zionist objection and lack of funds nipped this initiative in the bud.Footnote 57
In addition to attendance at schools in the region, some Palestinian doctors studied in Europe, particularly in the UK, France, and Switzerland, and these years had a lasting impact on their intellectual and political makeup. Ophthalmologist Khalil Budayri, for example, mentions meeting Lebanese Druze politician Shakib Arslan during his studies in Geneva as the latter was visiting the League of Nations, as well as Syrian and Lebanese medical and law students. He owed his Marxist education to these formative years.Footnote 58 Due to the availability of medical studies closer to home, however, only a few Palestinians studied in Europe. Our list of about 400 Palestinian doctors who worked in Palestine throughout the Mandate years includes five who studied at Montpellier in France, five who studied in Edinburgh, three in Geneva, and three in Paris.
DOING THE MINIMUM: THE COLONIAL STATE AND MEDICAL SERVICES
The structure of Mandate rule affected the professional status of doctors and their employment opportunities. A collective biography of the longest-serving health officials at the Mandate Department of Health (DOH) is illustrative. Most of them were born in the mid-1890s, and more than 80 percent graduated from SPC during or around World War I. Many had served in the Ottoman state or military and after the war laid the foundations of the DOH.Footnote 59 The DOH and this distinctive cohort had shared interests: the former needed young doctors to establish the department at minimum cost, whereas the latter were in dire need of financial stability in the precarious postwar job market. Government employees earned less than established private practitioners did, but a steady salary provided exactly the opportunity young doctors needed.Footnote 60
The state's approach to the Arab medical profession in Palestine reflected the Mandate's dual role. On the one hand, the League of Nation's Convention entrusted it with “rendering of administrative advice and assistance by a Mandatory until such time as they are able to stand alone,” and on the other the specific Mandate for Palestine required establishment of a “national home” for Jews. Moreover, although the Mandate recognized the autonomy of the Zionist institutions, it failed to establish parallel institutions for the Arab community and refused to recognize its existing representative institutions, a policy that further frustrated the establishment of national institutions.Footnote 61 This duality had concrete implications for local medical services. As the Jewish community started building its own quasi-state medical infrastructure, which relied on foreign Jewish capital and patients’ regular sick fund payments, the Arabs lacked resources and manpower. Mandate authorities, for their part, tried to balance their commitment to both communities. However, with a health budget that never exceeded 4 four percent of the total government expenditure, the authorities limited themselves to the bare minimum. Indeed, the initial British policy was “to limit, as far as possible, the hospital accommodation provided by the Government for general diseases to the requirements of civil servants, members of the police force, prisoners, medico-legal cases and accidents, and the very poor.”Footnote 62
In 1933, a reservation was added to this stipulation: “except where no private practitioner or other medical assistance is available,” an addition that reflected changing policies.Footnote 63 Growing criticism of the uneven services provided to the Jewish and Arab populations, particularly following the 1929 disturbances and then during the 1936–1939 Arab Revolt, led the British authorities to reconsider their health policies. We will discuss below the implication of this change for the relationship between Jewish and Arab doctors. Here we concentrate on the medical infrastructure and on Palestinian doctors themselves.
By the late 1930s, at least officially, the DOH took a much more comprehensive responsibility for the Palestinians’ well-being, expanded its personnel, and increased its budget, although by no means matching it to the Jewish counterpart or even the existing missionary facilities. Government hospitals more than doubled their share of Palestine's bed strength, from 14 percent in 1925 to 33 percent in 1944.Footnote 64 The size of missionary hospitals remained stable, whereas government hospitals in Jerusalem and Haifa doubled in the 1930s. In addition, when community and municipal hospitals in Gaza, Jaffa, and Nablus struggled to survive during the Arab Revolt, the Mandate authorities took them under their wings and expanded them (see Figure 1).
(color online) Bed Strength of Government Hospitals in Mandate Palestine
In the 1930s, moreover, the DOH began investing in public clinics, particularly in an effort to combat infant mortality and eye diseases. Both preventive measures were designed to combat what were considered by the British to be the two major ailments of the East: mothers’ ignorance, which was deemed responsible for infant mortality; and trachoma, which was the main cause of blindness. Targeted efforts to combat child mortality and blindness affected statistics most directly and were therefore highly publicized in British annual reports to the League of Nations.Footnote 65 In 1926, for example, Mandate authorities operated fifteen public clinics, six ophthalmic dispensaries, and eight infant welfare centers (IWCs). By 1939, trained medical orderlies operated ophthalmic services (which included a traveling ophthalmic unit), eight town clinics, three town special centers, and twenty village first-aid units, whose personnel regularly visited neighboring villages; the IWCs now numbered thirty-nine, found mostly in Arab villages and urban centers.Footnote 66 By the mid-1940s, there were twenty-one outpatient clinics in cities and towns, nineteen weekly village clinics, and thirty-eight IWCs, twenty of them in villages; seven additional IWCs were operated by local voluntary committees.Footnote 67 The gradual expansion of government, mission, and private health services remained confined mostly to the urban centers. Deprived of these services, yet gaining growing awareness of their benefits, the rural periphery's demand for professional services played a crucial role in the development of the profession. Yet sources tell us very little about patients and their relative preferences for traditional healers, Palestinian doctors, or their Jewish counterparts. Petitions sent to the DOH, newspaper articles, and ads do convey some patients’ responses and demands.
Most Palestinian villages had no medical personnel: a trained nurse, sometimes supplemented by weekly visits by a physician, was a privilege few Palestinian villages enjoyed. Shafa ‘Amr was one such village, with a clinic operated by the Christian Missionary Society nurse and weekly visits by a Nazareth doctor.Footnote 68 Burayr's inhabitants opened a clinic in their village frequented by a nurse and a doctor three times a week and once a week, respectively. The clinic in Khan Yunis was frequented by a doctor two or three times a week, and also by a male nurse and a certified midwife.Footnote 69 In 1932, Gaza's medical officer, Dr. Iskandar Haurani, visited Khan Yunis every Thursday, and Acre's medical officer, Dr. Manouk Erdikian, held a weekly clinic in Kafr Yasif.Footnote 70 Some villagers had better access to hospitals than others: villagers from the Acre region, for example, went to Acre or Haifa for complicated procedures.Footnote 71 Jenin and Acre, homes to either a small hospital or a small group of doctors, attracted patients from neighboring villages.Footnote 72 Most villages had no medical personnel and had to rely on traditional practitioners or visits to a nearby Jewish colony. Testimonies collected by Walid Khalidi mention several categories of practitioners who treated patients in the countryside: the midwife (d āya), the barber (ḥallāq), and the bonesetter (mujabbir), who lived in the village or were summoned from neighboring ones.Footnote 73
Although the DOH's highest-ranking officials remained British throughout the period, district health officers and senior health officers were predominantly Arab and Armenian—in proportions that reflected their percentage of the population, but not their proportion of the medical profession in Palestine as a whole, which, as will be described, was overwhelmingly Jewish. Most government doctors, moreover, were very mobile and served only a few years in each position before being transferred to another part of the country. This burdensome geographical mobility (a characteristic of other government jobs as well, such as teaching), however, did not compromise loyalty or reliance on the post, as most remained in government service throughout their career. As years went by, the young doctors opened their own private clinics while continuing their government employment, supplementing government employment with private practice. One report noted that doctors favored their private practices over their government posts, undermining service quality.Footnote 74
Appointed in the summer of 1946, Dr. Hugh Moeley Oliff Lester, the last director of the DOH, sought to solve the problem by promoting a few Palestinians to higher posts until then occupied exclusively by British officials, and by shortening the promotion track and raising the salaries of DOH employees.Footnote 75 Lester's reform also reflected colonial acknowledgment of the need for greater local empowerment in government to strengthen the sustainability of the health system. The turbulent period in which Lester's plan was conceived prevented its materialization.
JEWISH DOCTORS
The massive expansion of the autonomous health services of the Jewish community in Palestine and the influx of immigrant Jewish doctors, particularly after 1933, affected government policies and both the Jewish and Arab medical communities. Highly skilled and organized, the Jewish doctors not only posed a challenge as contestants for government funds and services, but also cast a shadow on every aspect of the slowly growing Palestinian medical community. This gap brought forward new political concerns, turning medicine into another realm of the Arab-Jewish conflict.
The superior development of Jewish health services reflected the imbalance of power between the two communities in Palestine. It also had its professional specificities. Following the Nazis’ rise to power, hundreds of Jewish doctors who had lost their livelihood in Germany immigrated to Palestine, increasing the number of Jewish doctors to more than 2,000. By 1937, their ratio rose to 1:176 in the Jewish community, compared to 1:3,779 in the Arab community (see Figure 2).Footnote 76 The Palestinian newspaper Mir'at al-Sharq commented, with sarcasm, that the ratio in Palestine had reached the point that every Jewish family had its own doctor.Footnote 77
(color online) Licensed Doctors by Nationality in Mandate Palestine, 1920 –1942
This posed a concrete economic and professional challenge to the Arab doctors, who now had to compete with an eventually tenfold Jewish counterpart, made up of graduates of major European universities, who also had a wide range of medical specializations that Arab doctors lacked. Moreover, the Zionist nation-building efforts entailed the formation of multiple medical institutions, which compensated for the British authorities’ neglect and targeted mainly Jewish patients.Footnote 78
Even before the immigration wave from Germany, the Simpson Report (1930), drafted by the British commission of inquiry into the 1929 unrest in Palestine, pointed to the negative influence of the growing number of Jewish doctors on the employment of Arab ones and noted that Jewish families rarely consulted Arab doctors, whereas Arab families often consulted Jewish doctors.Footnote 79 In 1932, the Jaffa-based newspaper Filastin observed the disproportional numbers of immigrant doctors, which grew sharply with the Nazi takeover of Germany.Footnote 80 This professional competition also found its way into the testimony of the Secretary of the Arab Executive, Jamal al-Husayni, before the 1937 Peel Royal Commission of Enquiry, arguing that Jewish doctors did not improve health conditions in Palestine, but lowered the salaries and threatened the livelihoods of their Arab counterparts.Footnote 81 In Conflict in the Land of Peace, a national political manifesto against Zionist claims published during the first months of the Arab Revolt, Dr. Kan‘an sought to refute the Zionist argument of improving health conditions in Palestine: “Statistics show clearly that the Jews have received infinitely more medical help from non-Jewish institutions than non-Jews have received from Jewish institutions. Despite these facts, the Jews continue to boast of the great medical help extended to non-Jews,” ignoring all the work done by the DOH and forgetting that their wars against malaria, for example, were fought primarily for their own settlement interests.Footnote 82 Al-Husayni and Kan‘an's grievances shed light on the political meaning of health services during the period: refuting the Jewish settler community's claims to have improved health for the Arabs also refuted the claim that the Zionist project was beneficial to all of Palestine's inhabitants.
The licensing of immigrant Jewish doctors became a highly charged political issue. After the establishment of the Palestine Arab Medical Association al-Jam‘iyya al-Tibiyya al-‘Arabiyya al-Filastiniyya) in 1944, the plea to reduce the quota for Jewish doctors became a formal demand presented to the director of the DOH, because of the fear that a new wave of postwar immigrants would once again flood the job market.Footnote 83
Appointments to the DOH were yet another source of tension. In this case, criticism arose over the clear preference of Arab over Jewish doctors, which failed to represent the latter's much higher number. In 1925, Palestinians (Arabs, Armenians, and Greeks) represented 22.7 percent of all doctors, a rate that would drop dramatically to 10.5 percent in 1935 and to 7.2 percent in 1947. In 1939, eleven Jews, sixteen Britons, and forty-six Arabs (including Arabic-speaking Armenians and Greeks) were employed by the DOH. In 1947, it employed 105 doctors, sixty-five of whom were Arabs and twenty-six Jews—sustaining a consistent ratio of 62 to 63 percent Arabs.Footnote 84
Jewish doctors were not only a source of conflict, however. In mixed cities, Arab and Jewish doctors worked as associates or shared a clinic and, in some instances, formed collegial and cooperative ties.Footnote 85 Jewish doctors were also a valuable resource, as they also operated private clinics in Arab towns and villages such as Bayt Safafa, Jericho, and Bethlehem. One survey of the town of Bayt Jala noted that they were called “shilling doctors” by the locals, as they were not yet formally licensed.Footnote 86 Jewish doctors also served Arab patients in their private clinics in Jewish towns and collective settlements (kibbutzim). Villagers from the Galilee mentioned Dr. Nathan Weill's clinic in Nahariya,Footnote 87 ‘Ayn Hawd's inhabitants went to Atlit,Footnote 88 Bashit's inhabitants remembered a Jewish doctor nicknamed Umm Yusuf from Yibna,Footnote 89 and villagers from Bisan district frequented a female doctor in Afula.Footnote 90 Lifta's inhabitants, for their part, benefited from the Shaare Zedek hospital in Jerusalem.Footnote 91 In some kibbutzim, separate clinics were built for Arab patients from neighboring villages.Footnote 92 An op-ed published in the leading Hebrew newspaper Davar in 1945 noted the treatment of Arabs by Jewish doctors in large factories and British military camps, where Arabs and Jews worked together, often in clinics of Kupat Holim, the health maintenance organization operated by the Histadrut, the Jewish labor union federation. According to the article, hundreds of Arab workers unionized under the Histadrut were also treated in Kupat Holim clinics. The author, a senior official in Kupat Holim, criticized the Arab doctors who incited sentiment against Jewish doctors who were “doing their job” for not settling in villages.Footnote 93
Whether they were helping or harming Arab health in Palestine, the evident progress of Zionist health services marked, for the Arabs, yet another realm of Palestinian society in peril. Perhaps here there is a resemblance to other colonial case studies, in which the colonizer provides a service to the natives but does so only to secure its colonizing end. This process had a determinative role in the mobilization of Palestinian doctors toward national professional self-determination, institutionalization, and unification of the community.
ARAB DOCTORS MOBILIZE
In June 1933, as described earlier, the first Congress of Arab Doctors in Palestine was held in Haifa. The resolutions merged political and professional agendas by focusing on the profession's relationship with the colonial authorities and the professional threat posed by the immigration of Jewish doctors, and demanding a freezing of licenses to immigrants, exclusive employment of Arab doctors in government institutions and departments, and the establishment of an independent Arab licensing committee. The delegates also expressed general opposition to the Mandate, the 1917 Balfour Declaration, and Jewish immigration. To implement the resolutions and expand the membership, an executive committee was charged with establishing a Palestinian Arab medical association—a task completed eleven years later.Footnote 94
At the local level, forming associations enabled Palestinian doctors to promote their objectives in the urban context even before WWI. City-based medical societies had organized sporadically in Palestine since the late Ottoman period; in Jaffa, for example, a society of doctors and pharmacists was established in 1912.Footnote 95
In addition to this localized activity, beginning in the early 1930s, Palestinian doctors joined regional networks. They were regular participants in the annual meetings of the Egyptian Medical Association, held first in Egypt itself and beginning in 1931 in neighboring countries. The Sixth Annual Congress of the association was held in April 1933 at the YMCA in Jerusalem, attended by seventeen doctors from Jerusalem, three from Jaffa, two from Haifa, and one from Jenin. Palestinian doctors gave lectures and served on the executive committee and scientific committee.Footnote 96 In addition, the Tel Aviv Medical Association invited delegates to witness the development of the Jewish health system. En route to Tel-Aviv, they stopped at the outskirts of Jerusalem at the Jewish Convalescent Home at Motza. After welcoming speeches by Tel Aviv's mayor, Meir Dizengoff, and the president of the city's medical association, they visited the Tel Aviv infant welfare center, Hadassah Hospital, and later, in Jerusalem, the Nathan and Lina Strauss Health Centre. Iraqi physician Faʼiq Shakir described the Hadassah infant care and school health services, noting anti-trachoma and antisyphilis measures. The excellent care for infants and children, he concluded grimly, would eventually lead to a Zionist victory. The cordial Zionist welcome was balanced by the Mufti Haj Amin al-Husseini, who invited the delegates to witness the annual Nebi Musa festival of mass pilgrimage to the burial ground of the prophet Musa.Footnote 97
Palestine's Arab doctors continued to participate in the Egyptian Medical Association's meetings, which in 1938 were rechristened Arab Medical Conferences. The Palestinian question and the urgency of the struggle came up regularly in the discussions. The 1945 Cairo Conference took a particularly strong stand: one of its resolutions included a boycott of Zionist pharmaceutical companies, and doctors pledged to refrain from prescribing their products. At the Aleppo Conference held the following year, country representatives pledged a donation of a total of 50,000 pounds for the establishment of medical institutions in Palestine, a pledge that as far as we know was never fulfilled.Footnote 98
In October 1944, a local Palestinian Arab Medical Association was finally established, bringing together medical associations from Haifa, Jerusalem, Nablus, Gaza, and Jaffa. By December, an all-Palestinian executive was elected in order to hold a national conference.Footnote 99 The conference was held at the YMCA in Jerusalem in July 1945. Over 200 doctors and pharmacists, as well as Palestinian intellectuals and religious and public figures, including mayors, foreign consuls, and senior British government officials, attended the opening. Director of Medical Services Dr. John Macqueen gave his blessing and urged the young generation of Arab doctors to address the dire shortage of doctors in Arab villages and towns.Footnote 100 Macqueen's presence highlighted the organizers’ ambivalence toward the government. They were critical of its limited achievements in the Arab sector and its support of Zionism on the one hand, but depended on its funding and administration and still considered it a relevant partner on the other. Earlier that year, Dr. Tamimi, a central driving force behind the association, had voiced bitter criticism against “the Mandate, [which] knows how to build dozens of fortresses for the police in Arab Palestine, [but] does not know how to build one clinic for tuberculosis patients.”Footnote 101 The conference raised several demands, including sending more Arab doctors for specialization training at British universities; increased government expenditure on health; the establishment of new hospitals; and recognition by Mandate authorities, hence a demand to be consulted regarding new regulations limiting the number of Jewish doctors.Footnote 102
The association's achievements were mainly symbolic: neither budgets nor donations were secured. In April 1945, for example, it signed an agreement with the Palestine Broadcast Service and launched weekly ten-minute radio lectures on health issues.Footnote 103 In November, the association's journal was launched, with Dr. Mahmud Tahir al-Dajani as its editor in chief. The editorial board included Palestinian doctors Tawfiq Kan‘an and Futi Frayj, as well as Muhammad Khalil ‘Abd al-Khaliq, Fu'ad Ghusn, and Jamil Basha Fa'iq al-Tawtanji, heads of the Cairo, Beirut, and Amman associations, respectively. This impressive membership and the content of the journal reflected the high academic standards and pan-Arab ethos that the journal sought to propagate. Charged with a national sense of purpose, the first issue included greetings from the presidents of the Iraqi and Jordanian associations.Footnote 104 “For Science, Humanism and Arabism,” read the title of an article by ‘Ali Ibrahim Basha, former Egyptian Minister of Health and president of the Egyptian Medical Association, founder of its journal, and Dean of King Fu'ad I University.Footnote 105 The journal was published until the spring of 1948, and, although short-lived, provided a professional academic platform for Palestinian doctors. In 1947, the association started raising funds for the establishment of new hospitals, but these efforts were interrupted by the outbreak of the war that was to put an end to its activities and to the emerging Palestinian nation-building effort in general.Footnote 106
Considering the similarity of the association's resolutions, members, and objectives to the 1933 Haifa conference, the reason for the eleven-year gap before its establishment is unclear. Historian Muhammad Qarqara offers several explanations. The first is the small number of doctors who were divided between the government, the different missions, and private clinics. The second is the reluctance of the urban elite to take responsibility for the poor villagers. The changes in these tendencies, he argues, were too little and too late, a by-product of the growth of the medical community. When the association was finally established, lack of funding, a shortage of trained physicians, and the absence of a tradition of caring of the poor prevented it from achieving its goals, mainly that of providing health services to all Palestinians. The national leadership, primarily the Higher Arab Committee headed by the mufti, never took real interest in providing medical services. First-aid initiatives in times of violent clashes such as the Arab Revolt never went beyond local voluntary efforts. The Supreme Muslim Council, the wealthiest institution, also took only limited action. Only in the 1940s did a few municipalities, mainly Jaffa and Ramallah, start collecting a health and welfare tax. Historian Nira Reiss, moreover, argues that “the religious Muslim basis and the conservative leadership of the Arab national movement continued to favor traditional forms of social assistance, i.e., charity based on the collection of zakat funds and on the allocation of waqf income.”Footnote 107
We believe these conclusions lay too much responsibility on Palestinian doctors for circumstances beyond their control. The violent British counterinsurgency against the Arab Revolt and the exile of Palestinian leadership were only a prelude to the long years of WWII, during which, again, the national impetus and state-building initiatives were put on hold. After the war, the Palestinian social body could once again raise its head on a national level and reclaim its rights. Again, however, it found itself in the same internal political strife, lacking a united leadership and functional and well-funded national institutions. Looming over the horizon was the collapse of medical services during the 1948 war. Therefore, we find it problematic to judge the sustainability of this short-lived association, established in turbulent times in Palestine, only two and a half years before war erupted. Evaluating the honest efforts of Palestinian doctors only in the context of 1948 necessarily leads to biased and anachronistic conclusions.
We can ascribe the belated emergence of a nationwide Palestinian medical association also, if not primarily, to the regional professional and political identity of local doctors. Relatedly, their strong connections to the neighboring Arab associations—through their education and their continued participation and central roles in regional conferences—might have made a national Palestinian organization seem redundant. The British policy of excluding Palestinian doctors from leading positions in the DOH further compromised the potential organization on a national level, limiting empowerment of doctors to, at best, the local and temporary. This weak countrywide organizational structure affected the profession's preparedness for the 1948 war: medical assistance could be organized on a local level, but coordination was minimal, as was assistance from neighboring medical organizations. Doctors and hospital staff were left virtually on their own.
CONCLUSION
In the course of three decades, an ever-expanding community of trained doctors, both Arab and Jewish, gradually turned the desolate field of modern medicine in Palestine into a contested forest of clinics, hospitals, and regional networks. The expansion of primary and secondary education during the Mandate period, a process that had begun in the late Ottoman period and reached its apogee in the mid-1940s, allowed access to medical studies to larger communities of relatively greater diversity. These possibilities also marked the shift of academic training to being a source for symbolic and cultural capital, and therefore for social mobility and political influence.
As demonstrated here, the Palestinian medical community was formed despite Mandate policies, with the use of personal and sometimes communal resources. Studying abroad connected medical professionals to regional networks, which also reduced the need for a Palestinian medical association before the mid-1940s. The competition with a larger community of settler doctors affected the availability of medical services outside urban centers and provided opportunities for contact and collaborative work. It also politicized the Palestinian Arab medical community and shaped its demands vis-à-vis Mandate authorities.
The conceptualization of the profession in the colonial context highlights the resourcefulness of a colonized society that relied on its own resources to form a medical community. It also highlights the ambivalence of this community's relationship with the colonial power, as source of employment on the one hand and bitter political rival on the other. Sociological models of the professions, blind to race and ethnicity, would not have allowed for such an antagonistic relationship. Education in such models is analyzed in terms of national education, but in Mandate Palestine education created and fostered multinational professional and political networks. When it comes to the profession itself, the settler-colonial context entailed a conflict, affecting the stakes within the field. Professional competition and national ideology created multiple realms of intersection, making the medical profession a microcosm of the conflict over Palestine. A future study can take the story through the post-1948 years and the survival and development of the profession both in the diaspora and at home, under Israeli, Egyptian, and Jordanian rule.
