Dr. Harvey Cushing, the father of modern neurosurgery, once wrote that, “A physician is obligated to consider more than a diseased organ…more even than the whole man - he must view the man in his world.”¹ As American medical students studying abroad, we are travelers in a foreign social and historical narrative and are exposed to political conflicts which are not our own and which test our dedication to the universal and humane principals that define our profession. Nowhere is this truer than in Israel, where it is impossible to escape the conflict which overshadows the region and has resulted in two brutal wars in just the last four years and the deaths of thousands of Israelis and Palestinians. However, Israel’s social problems do not exclusively stem from the conflict with the Palestinians, the Occupation and its ongoing tensions. In recent years, Israel has found itself at a new crossroads, the result of an under-reported struggle to absorb thousands of non-Jewish refugees fleeing violence and dispossession in South Sudan. The presence of these refugees stirs profound ethno-religious tensions in Israeli society and raises the question of what, if anything, does the state founded by the survivors of Europe’s genocides owe to refugees the world over. As the humanitarian situation worsens in Sudan,^2,3 more and more of these individuals are making the desperate journey of thousands of miles across the desert, and into community clinics, where many of the American medical students studying in Israel’s three international medical schools regularly volunteer. In this article, I will explore the pressing health needs of these refugees, detail the clinical and ethical issues in their care, and present how their presence in the Israeli health care system is an opportunity for aspiring physicians to practice humanistic medicine across ethnic and political lines.

I first came into contact with South Sudanese patients during my first year of medical school while volunteering at the Tel Aviv Open Clinic run by Physicians for Human Rights - Israel. The clinic is located in south Tel Aviv, where many of these refugees live in crowded tenements and struggle to find work. PHR-Israel is a non-partisan, non-profit medical organization founded in 1988 in the midst of the First Intifada by a diverse group of Israeli and Palestinian physicians with the goal of achieving and defending human rights, in particular the right to health, for all people living in Israel and the Occupied Territories.¹ In the last few years, PHR-Israel has taken the lead in advocating for Sudanese refugees by supporting government policies which promote social justice and universal health access.⁵ At the same time they provide health care to underserved populations, including migrant workers, refugees and Palestinians both for humanitarian reasons and because they believe that health gaps in community members can have significant repercussions for the entire society.^7,8,9 PHR-Israel is a sister organization of the larger international Physicians for Human Rights organization known for its work on many fronts including the promotion of human rights worldwide, medical neutrality in conflict regions, HIV/AIDS advocacy, and the banning of landmines.

To return to that night in the community clinic in south Tel Aviv, I must admit that prior to that moment, I was only vaguely aware that things were not well in Sudan. I had heard of the conflict in the region but did not know who was killing whom or for what reasons. As I worked alongside the volunteer physicians and nurses, I learned how many of these refugees came to the Open Clinic because their families were without legal standing in Israel and therefore unable to access the government-managed health care system.^11,12 In Israel, where a Jewish individual born in Brooklyn or Sydney faces no obstacles to full citizenship and receives significant government benefits upon immigration, these desperate refugees fleeing extreme violence – if not genocide - in their home countries often live day-to-day under the constant risk of deportation without any track to citizenship.¹³ Those who are officially recognized as asylum seekers often do not receive work permits to support themselves.^14,15,16 These factors are exacerbated by the government’s policies towards the family members of refugees under the National Insurance Law. This bill stipulates that people without Israeli citizenship are to be excluded from state funds and must receive insurance through their employer or purchase their own private insurance which results in many of these destitute families to go without any health coverage.¹⁷ Furthermore, unlike in the United States or France, where a child becomes a citizen by birth on its territory, in Israel the children of undocumented non-Jewish refugees remain stateless. This approach to immigration creates an environment where families of refugees must struggle to receive equal access to education or health care and have little opportunity to assimilate into Israeli society.¹⁸ Though a humanitarian apparatus exists to provide these children of foreign immigrants with a basic level of health care, the system is inadequate: it requires a waiting period of six months, is restrictively expensive, and excludes all pre-existing conditions.¹⁹ In short, the plight of the South Sudanese refugees – already in challenging enough circumstances after surviving considerable physical, psychological, and social trauma – is compounded due to the unique political, religious, and ideological realities of Israel.

One particularly unfortunate patient stands out in my memory. James [NB: name changed to protect privacy] was born in Sudan before his family fled thousands of miles from their home to settle in the bleak desert town of Arad. Somewhere along the way, he contracted meningitis, which left him impaired physically and cognitively. At nine years of age, James still wore diapers and had difficulty walking and speaking. The family had traveled across the country from Arad to the Open Clinic in south Tel Aviv to ask if we could do something for him. The mother could no longer watch him daily as she needed to work outside the home. The family had no understanding of the etiology or severity of their son’s condition and had never seen a physician about his disabilities. As we told them in a mixture of broken Arabic and English that the damage had occurred years ago and there was nothing we could do, things were made worse by the fact that we could not even refer them to a special education facility because they were not citizens and had no access to social services or the formal health care system.

Though not all Sudanese face such bleak medical issues, their situation is compounded by a political and ideological situation which strives to draw clear lines about who is welcome and who is not. This dichotomy can be best understood by examining the situation of Jewish Ethiopian refugees fleeing the instability in their country against that of their non-Jewish Sudanese neighbors. Though still not fully assimilated, thousands of Jewish Ethiopians were actively brought to Israel in the 1980s by the government, given full citizenship and immigrant benefits.^20,21 The situation of the South Sudanese is very different: many are lacking legal immigration status and therefore face active discrimination and risk detainment or deportation on a day-to-day basis.²² The United Nations High Commissioner for Refugees surveyed nearly 5,000 Sudanese refugees living in Israel with 2,200 new asylum seekers arriving in 2009.²³ In November 2009, Israeli Finance Minister Yuval Steinitz blamed foreign workers and refugees for a rise in unemployment and a “widening of social gaps”, while the mayor of the city of Eilat, Meir Yitzhak Halevi, recently declared that refugees “consume alcohol and have introduced cases of severe violence.”²⁴

While we can distinguish between the individual and institutionalized discrimination faced by non-Jewish Africans in Israel and a modern state’s policing of its borders against illegal immigration, unlike in other developed countries, these issues are driven by underlying questions of ethnic and religious identity in a country where both are extremely contentious. To emphasize the discriminatory government action against refuges, it was only in August 2009 that the “Gadera to Hadera” rule was revoked by the Interior Ministry of Israel. This rule restricted even legal Sudanese asylum seekers from living in the Tel Aviv-Jerusalem corridor - the commercial center of the country, where many gravitate to find employment.²⁴

To understand the significant challenges these non-Jewish refugees face in achieving health care and ensuring basic human rights, it is essential to understand the political and ideological motivations which drive these discriminatory policies and which shape how the self-described “Jewish and Democratic” state handles refugees. Israel is a developed industrial country with a representative democracy and highly educated population. However unlike economically similar countries in North America or Europe, Israeli political thought is shaped by the philosophy of Zionism, which argues for the necessity of an ethnically defined state to protect individuals of Jewish ancestry from persecution.²⁶ The goal of this article is not to debate this ideology as to whether it is justified or inherently racist; however it is undeniable that this line of thought has led to multiple conflicts with non-Jewish individuals both within Israel and outside of it over the last sixty years. One fundamental question in the Israeli political dialogue since the inception of the state has been what rights do non-Jewish Israeli citizens have in the Jewish state, whether they are Israeli Arabs, members of the regional Druze minority, or non-Jewish family members of Soviet Jews. The arrival of the South Sudanese, many whom are Christian, in the last few years has highlighted this issue, with the added dimension that they are refugees fleeing horrific violence in their country. In a society that itself as “Jewish and Democratic”, the pressure to avoid diminishing the Jewish identity of the state comes into tension with democratic principles that should protect the human rights of the South Sudanese – particularly under the 1951 U.N. Convention Relating to the Status of Refugees, to which Israel is a signatory.²⁷

Through advocacy and volunteer medical work, medical students can both improve the situation of the South Sudanese directly and help ensure that the government of Israel lives up to its responsibilities as a member of the world community. As future physicians striving to practice a universal and humanistic medicine, this tension is a profound opportunity to work across social and ethnic divisions for the betterment of all members of society. In addition to volunteering at local medical clinics such as the Open Clinic, many American medical students in Israel have become involved with advocacy and outreach efforts towards the South Sudanese and larger African refugee community. One such organization is the African Refugee Development Center (ARDC) in Tel Aviv, founded by a former Ethiopian refugee named Yohannes Bayu, who after arriving in 1997 fought for five years to have his status officially recognized through legal action against the Interior Ministry in the Israeli Supreme Court. The ARDC works to promote a humane asylum policy by lobbying the government and to provide basic social services while helping refugees integrate and become self-sufficient. Volunteers at the ARDC assist refugees from South Sudan, as well as Eritrea, Liberia, Ethiopia, and the Ivory Coast by providing medical care, trauma counseling, assistance in the asylum process, and employment and housing opportunities for refugees.²⁸ Programs such as the ARDC show that medical students can make a difference outside of the clinic.

The former U.N. High Commissioner for Refugees, Paul Hartling, once wrote, “A lasting solution, the possibility to begin a new life, is the only dignified solution for the refugee.”²⁹ As medical students, it is our duty to help patients who come to us as refugees achieve that new life while promoting efforts that encourage greater social justice in our communities. We often find ourselves overwhelmed by the tedious nature of studying and preparing for exams; however, working with underserved communities, whether they are in the slums of inner-city America or in Israeli refugee clinics, allows us to think outside of ourselves and to fully realize the universal and humane principals which undergird our profession. The South Sudanese refugee crisis is a useful case study for medical students the about working through both government and non-governmental avenues to advance health and human rights. International medical students have the unique opportunity through exposure to various conflicts and crises around the globe to expand our education through a framework of clinical and humanitarian experiences which will enrich our perspective as physicians.

Daniel Wasser is a second year MD student at Tel Aviv University's Sackler School of Medicine in Israel. He is also the Co-Director of Physicians for Human Rights-Israel's Student Chapter. He can be contacted at danwasser86@gmail.com.

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