Social Science & Medicine 74 (2012) 839e845

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Social Science & Medicine

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Medical humanitarianism, human rights and political advocacy: The case of the
Israeli Open Clinic
Nora Gottlieb a, Dani Filc b, Nadav Davidovitch a, *
a
Department of Health Systems Management, Ben-Gurion University, POB 635, 84105 Beer Sheva, Israel
b
Department of Politics and Government, Beer Sheva, Israel

a r t i c l e i n f o a b s t r a c t

Article history: In the context of neo-liberal retrenchments humanitarian NGOs have become alternative healthcare
Available online 23 August 2011 providers that partially fill the vacuum left by the welfare state’s withdrawal from the provision of
services to migrants and other marginalized populations. In many cases they thus help to build legiti-
Keywords: macy for the state’s retreat from social responsibilities. Human rights organizations play an important role
NGOs in advocating for migrants’ rights, but in many cases they represent a legalistic and individualized
Medical humanitarianism
conceptualization of the right to health that limits their claims for social justice. This paper analyzes the
Human rights
interactions and tensions between the discourses of medical humanitarianism, human rights and
Political advocacy
Migrant workers
political advocacy using the example of an "Open Clinic" run by an Israeli human rights organization as
Asylum seekers a case-study: In 2007 dramatically increasing patient numbers provoked an intense internal debate
Access to healthcare concerning the proposal to temporarily close the "Open Clinic" in order to press the government to take
Israel action. Based on protocols from internal meetings and parliamentary hearings and in-depth interviews,
we have analyzed divergent contextualizations of the Clinic’s closure. These reflect conflicting notions
regarding the Clinic’s variegated spectrum of roles e humanitarian, political, legitimizing, symbolic,
empowering and organizational e and underlying conceptualizations of migrants’ “deservingness”. Our
case-study thus helps to illuminate NGOs’ role in the realm of migrant healthcare and points out options
for a possible fruitful relationship between the divergent paradigms of medical humanitarianism, human
rights and political advocacy.
Ó 2011 Published by Elsevier Ltd.

Introduction persons, including prisoners or detainees, minorities, asylum seekers

As a consequence of exclusionary policies undocumented migrants
and asylum seekers often face significant difficulties in accessing
healthcare services (PICUM, 2007; Ruiz-Casares, Rousseau, Derluyn,
Watters, & Crépau, 2010). Human rights and humanitarian NGOs gain
importance as service providers as, in the course of neo-liberal
reconfiguration, states retreat from responsibility for welfare services.
In many countries, NGOs’ humanitarian activities have become an
alternative source of services that compensates for welfare states’ roll-
back (Castaneda, 2009; Karl-Trummer, Novak-Zezula, & Metzler,
2009). Human rights and political advocacy, on the other hand, address
the question of migrants’ social inclusion by putting forward health
rights-claims, based e.g. on the UN General Comment 14, which
specifies that “[S]tates are under the obligation to respect the right to
health by. refraining from denying or limiting equal access for all
* Corresponding author. Tel.: þ972 50 5465479; fax: þ972 8 6477634.
E-mail addresses: norag@bgu.ac.il (N. Gottlieb), dfilc@bgu.ac.il (D. Filc), nadavd@
bgu.ac.il (N. Davidovitch).
and illegal migrants, to preventive, curative and palliative health
services” (UN, 2000). While humanitarian action, human rights-
claims and political advocacy all address undocumented migrants’
and asylum seekers’ exclusion, essential tensions exist between their
respective paradigms and practices, as these embody different defi-
nitions of “deservingness”. Humanitarian NGOs may, unwillingly, help
to build legitimacy for states’ retreat from responsibility for social
service provision and their exclusionary policies, since their discourse
is a discourse of charity and not of entitlement (Ticktin, 2006). Human
rights organizations may approach health and healthcare in individ-
ualist, legalistic-reductionist and top-down ways that decontextualize
health issues and even lead to communities’ disempowerment.
This paper addresses the tension between the different
approaches of medical humanitarianism, human rights and polit-
ical advocacy through an analysis of a debate within the Physicians
for Human Rights-Israel (PHR-IL) to temporarily close their walk-in
clinic for uninsured persons (“Open Clinic”) in order to pressure the
state to take responsibility for asylum seekers’ health. First we will
present an overview of the development of different paradigms

0277-9536/$ e see front matter Ó 2011 Published by Elsevier Ltd.

doi:10.1016/j.socscimed.2011.07.018
840 N. Gottlieb et al. / Social Science & Medicine 74 (2012) 839e845
guiding NGOs’ activities in the health realm, followed by
a description of our case-study and our methodology. Then we will
present our findings and, on this basis, discuss the tensions
between humanitarian, human rights and political approaches, and
the limitations of a de-contextualized approach to health rights. We
hold that NGOs should acknowledge those tensions as an oppor-
tunity to critically review their own activities and to more directly
involve the respective communities in the discussion of how to
address health rights issues.
Medical humanitarianism, human rights and political
advocacy
The classic understanding of medical humanitarianism has been
epitomized by the International Red Cross (IRC), which grounded
its intervention in four principles: humanity (assisting the suffering
without discrimination, based on common humanity); impartiality
(establishment of priorities only by need and urgency); neutrality
(helping victims without taking sides); and universalism (applica-
tion of the same approach regardless of location) (Chandler, 2001).
According to this view humanitarian activity is to be completely
separated from political activities in order not to jeopardize the
principles of neutrality and impartiality. Classic humanitarianism
implied a “thin” and a political understanding of “deservingness”,
based on common humanity, limited to basic alleviation of
suffering. The IRC’s philosophy has been adopted by several NGOs
that provide relief and assistance, mostly in areas of conflict or
disaster and in poor “Third World” countries (Smith, 1989).
The 1960s and 1970s saw the emergence of human rights orga-
nizations that shared the principles of humanity and universality
with humanitarian organizations. But instead of providing assis-
tance, avowing neutrality, and emphasizing the apolitical character
of their work, they challenged the legitimacy of states that
systematically violated human rights. Their goal was not to provide
assistance in emergencies, but to modify the political context that
allowed for human rights violations and created humanitarian
crises. These NGOs shared a legalistic and liberal understanding of
human rights that remained relatively blind to the political and
social embeddedness of rights and to the complex interaction
between colonialism, imperialism and the rights-discourse. They
represented “deservingness” as emerging from, but also limited by,
an individualist and legalist conception of rights.
Since the 1970s there have been three main developments in the
complex interaction between humanitarianism and human rights:
a) the development of a more political “new humanitarianism”, b)
the increasingly importance of NGOs in the provision of social
services in high-income countries following welfare states’ retreat,
and c) the expansion of the rights-concept to social and collective
rights, in parallel with the development of rights approaches that
transcend the juridical perspective by taking into account the
socio-economic and political context.
The new humanitarianism holds a critical stance toward clas-
sical humanitarianism’s apolitical approach, expanding humani-
tarian activities from “the provision of immediate assistance . to
the greater commitment of solidarity and advocacy work for
victims and concerns for the long-term protection of human rights”
(Chandler, 2001: 682). However, unwilling to sacrifice “their
neutral and ’non-political’ status” proponents of the new human-
itarianism justified “their strategic choices through the language of
morals and ethics rather than politics” (Chandler, 2001: 683). They
emphasized the need for témoignage, but still saw their role mainly
as providers of services in order to alleviate suffering (Fox, 1995;
Shevchenko & Fox, 2008).
The second development is the transformation of NGOs’ role as
service providers in the context of neo-liberal globalization. The
withdrawal of the state, the limitation of citizenship entitlements
and the recommodification of services are central characteristics of
neo-liberalism (Kamat, 2004; Jessop, 2002). Vis-à-vis a retreating
state, NGOs “attempt to fill the vacuum left by public social welfare
retrenchment and the negative social effects of free market
fundamentalism.” (Pyles, 2009: 2; Reich, 2002) Organizations like
Médicines du Monde and Médicines Sans Frontières have since the
late 1980s become involved in providing healthcare for les exclus,
“families of [both local] and foreign immigrant origins. vulnerable
to illness and without access . to decent medical care” (Fox, 1995:
1611). They have thus been instrumental to the process of neo-
liberalization and privatization, replacing the state as a provider
of services for vulnerable populations and alleviating the more
acute symptoms of deprivation “without challenging the causes”
(Gideon, 1998: 307).
The third process is the broadening of the rights-discourse
beyond a legalistic conceptions and the development of an
awareness of the socio-political embeddedness of rights. This
process is related to the development of the welfare state, in which
social entitlements are articulated in terms of social rights, and to
social movements’ integration of the rights-discourse into the field
of identity politics. While this process broadens the boundaries of
“deservingness”, it is far from all-encompassing. The vestiges of
a juridical, a political and individualistic inclination are revealed in
many human rights organizations’ appeal to a “moral discourse
centered on pain and suffering rather than [to a] political discourse
of comprehensive justice” and concentrate on the mitigation of
unjust distribution instead of addressing its structural causes
(Brown, 2004: 453).
Irregular migration and entitlement to healthcare in Israel
The distinct situation of undocumented migrants’ and asylum
seekers’ access to healthcare in Israel results from the interaction
between characteristics of the national healthcare system and
Israel’s immigration and citizenship regime. Access to healthcare in
Israel is regulated by the National Health Insurance Law (NHIL) of
1994, which establishes that every Israeli resident, officially
recognized as such by the Ministry of Internal Affairs, has equal
access to healthcare. The state is responsible for the provision of
health services through non-profit sick funds. However, eligibility
for residency status is shaped by Israel’s immigration and citizen-
ship regime, whose central piece of legislation is the Law of Return
that endows Jewish immigrants with immediate citizenship rights.
The Law of Return has not been complemented by legislation that
would entitle non-Jewish immigrants to permanent residency or
citizenship. This restrictive policy constitutes the legal basis for
broader processes of non-Jewish immigrants’ conceptualization as
“others” and consequent marginalization and exclusion (Filc, 2009;
Grove & Zwi, 2006). Migrant workers receive only temporary
permits and - with eligibility for coverage depending on permanent
residence e thus remain excluded from the NHIL.
Since 2001 the “Foreign Worker Order” obliges employers to
purchase private health insurance for migrant workers, indepen-
dent of the latter legal status. Theoretically the law stipulates
coverage similar to the NHIL. However, in reality, these guarantees
fall victim to power differentials and market imperatives and
consequently migrant workers’ access to healthcare is restricted
(Filc & Davidovitch, 2005). Especially undocumented migrants lack
access to primary and secondary care, as well as to elective hospi-
talization. Few public healthcare services are universally accessible
(exceptions include emergency care, primary maternal-and-child
healthcare, and treatment for tuberculosis and sexually trans-
mitted diseases). Alternative healthcare-options are the relatively
cheap hospitals of East Jerusalem, PHR-IL’s Open Clinic, and the
 N. Gottlieb et al. / Social Science & Medicine 74 (2012) 839e845
“Refugee Clinic” opened by the Ministry of Health (MoH) and the
Israeli Medical Association following the Open Clinic’s closure in
September 2008. However, Jerusalem lies in the Occupied Pales-
tinian Territories (OPTs) which makes access problematic; and the
latter are not capable of addressing the full range of migrants’
healthcare needs. Finally, language barriers and fear of arrest and
deportation increase migrants’ difficulties in accessing healthcare.
Asylum seekers constitute another population without access to
the healthcare system. Since the mid-2000s this group is rapidly
growing, mainly due to an unprecedented inflow of African asylum
seekers via the Egyptian-Israeli border. According to the UNHCR,
the number of asylum seekers and refugees residing in Israel has
risen from 365 in 1999 to 4409 in 2000 and 31,055 in 2011 (UNHCR,
2011). Persons who obtain formal recognition as refugees are
included in the NHIL. However, less than 1% of asylum seekers have
been granted refugee status (Nathan, 2011). Some asylum seekers
receive work permits but unless their employers purchase private
health insurance for them they are not included in any healthcare
scheme. Therefore, their situation is similar to that of undocu-
mented migrant workers.
Physicians for Human Rights-Israel (PHR-IL) was established in
1988, during the first Intifada, in order to denounce and oppose
violations of the right to health in the OPTs. The organization
consists of a board (most of them physicians), members and
volunteers (most of them healthcare professionals) and staff (with
a background of social activism). During the 1990s the organization
extended its fields of activity and defined its goals more broadly
within the framework of a general commitment to a universal right
to health, which includes not only universal access to healthcare
but also social determinants of health for all persons under Israeli
governance, especially marginalized groups such as Palestinians in
the OPTs, prisoners and detainees, Bedouin-Arab communities,
migrant workers, refugees and asylum seekers and lower-class
citizens. The creation of a project to address migrant workers’
health rights was one step in this process. It began with the opening
of the Open Clinic, where volunteers provided healthcare to unin-
sured persons, and developed into advocacy, lobbying and political
activism for the health rights of this population. Today the Open
Clinic forms a semi-autonomous part of the advocacy project,
operating five days per week to provide general primary care,
women’s healthcare and pediatric services.
The Open Clinic’s patient load increased in parallel to the number
of asylum seekers: Between 2006 and 2007 the average number of
patients rose from 300 per month to 100 per day. Whereas migrant
workers previously represented the main bulk of the Open Clinic’s
patients, the number of asylum seekers increased to 69% of the
patient population in November 2007 (Kaufman & Aviv, 2008; PHR-
IL, 2008). In addition, the Open Clinic volunteers reported
a dramatic increase in complicated problems such as gunshot
wounds and physical and psychological trauma following torture.
Moreover, most asylum seekers were poorer than the Open Clinic’s
previous patient population and could not afford medical services
the Open Clinic was unable to provide for free (e.g. laboratory tests,
drugs). Inadequate living conditions such as homelessness and
accommodation in improvised shelters created additional health
risks. These exigencies led to the Open Clinic’s near-collapse and
sparked an intense debate within PHR-IL about the Clinic’s opera-
tion under such conditions. The debate resulted in a decision to
temporarily close the Clinic in order to increase pressure on the state
to take responsibility for asylum seekers’ health. The variegated
spectrum of PHR-IL’s activities implies a constant tension between
a “new humanitarianism”, classic human rights advocacy and
a more political understanding of the conditions of structural
inequality and social exclusion. PHR-IL’s decision to temporarily
close the Open Clinic brought this constant tension to the fore in
841
a sudden and dramatic manner. The decision-making process and
discourse within PHR-IL thus provide an excellent opportunity to
shed light on the underlying questions described here.
Methodology
This study utilizes various qualitative methods: Firstly, in March
2010, we retrieved the protocols of discussions concerning the Clinic
closure, subsequent events, and the Clinic’s reopening that took
place within PHR-IL and performed a content analysis. Secondly,
between March and May 2010, we analyzed the protocols of rele-
vant discussions in the Israeli Parliament, all of which are available
online. Thirdly, between April and May 2010 we conducted semi-
structured in-depth interviews with six key informants: the
director of PHR-IL, members of the board, current and former
directors of the advocacy project, and former medical and admin-
istrative directors of the Open Clinic. The interviews addressed the
Open Clinic’s role within the framework of PHR-IL’s activities and
principles, including the interaction between humanitarian, human
rights and political perspectives, the contextualization of the events
that led to the Clinic’s closure, perceptions of the internal discussion,
interactions with other key players, and evaluations of the Clinic
closure’s outcome. The interviews were recorded, transcribed, and
analyzed using ATLAS.ti-software. We analyzed our data according
to both emerging and preexisting coding paradigms, thus gener-
ating our theoretical categories both deductively and inductively
(Mayring, 2000; Strauss & Corbin, 1994). The ongoing data collec-
tion helped to verify our concepts and continually refine our
emerging theory (Mayring, 2000). Furthermore respondent vali-
dation was used to ensure the validity of our interpretations (Strauss
& Corbin, 1994). All names used in the results-section are fictional in
order to safeguard our interviewees’ anonymity.
The ethical committee of the faculty of health science at Ben
Gurion-University (BGU) approved the research. It is important to
note that while all authors are affiliated with BGU, they are also
associated with PHR-IL. While this fact eased access and enhanced
tacit knowledge and understanding of the processes and discussion
within the organization, it undoubtedly influenced our findings and
interpretations.
Results
Our findings are divided into sub-sections according to the main
themes that emerged from our data: a) reasons for the Clinic’s
closure, b) the Open Clinic’s role and mandate, c) PHR-IL’s role and
mandate with regard to migrant healthcare, and d) perceptions of
the interaction between three different paradigms and modes of
action: medical humanitarianism, human rights work and political
advocacy.
Reasons for the Open Clinic’s closure
Our data suggest that the convergence of several interrelated
factors prompted the Open Clinic’s closure in March 2008. These
include a dramatic increase in patient numbers and needs;
concerns about the standard of care, both from a medical and public
health perspective; apprehensions about “becoming a fig leaf” for
the authorities’ inaction; and the willeand possibilityeto build up
public pressure and call the government to account for asylum
seekers’ healthcare.
Descriptions of the “refugee crisis” leave no doubt that the most
salient phenomenon surrounding the Open Clinic’s closure was the
escalation in patient numbers. Neta, the Open Clinic’s former
administrative manager, recalled that “the situation was pretty
catastrophic [.] I am standing there [.] and tens of patients standing
842 N. Gottlieb et al. / Social Science & Medicine 74 (2012) 839e845
around me shouting [.] the situation became really unbearable."
Accounts like the above are graphic and rich in detail, offering
a tangible experience of a situation in which clinic staff and volun-
teers felt literally overwhelmed. Ittay, the migrant worker project’s
director, explained that this overpowering situation resulted from
high patient numbers, from their problems’ severity and complexity,
and from unprecedented levels of destitution:“[M]ore and more
people arrived to the clinic and each demanded a much more complex
solution than what we provided [.].Eventually things reached a point
that we simply could not function [.]. The Clinic’s collapse [.] was the
trigger [for the closure].”
As it became impossible to maintain the previous standard of
care, concerns arose about the appropriateness of medical treat-
ment that the Clinic could provide under these conditions. Neta
concluded that "we ended up with a situation in which we neither
give care nor don’t give care. [In this situation] it was better to close the
Clinic altogether." Above situation "really created great frustration
among [.] both staff and volunteers" (Ittay). Several interviewees
recounted situations of distress and despair after various strategies
to cope with the “refugee crisis” failed and “nothing really resolved
the core of the situation. [In the board meeting] I cried. I remember it
was very hard.” (Neta) At the same time the authorities’ inaction
caused outrage, because even though “[t]hey were refugees [.]
everything fell on us" (Amos, PHR-IL board member and Open Clinic
volunteer). Yet, the PHR-IL staff’s indignation also contained
a certain amount of self-critique, assessing that "[h]ere we were
really doing work for a community that [.] is supposed to be taken
care of by the government. [.] I thought that I was actually working
against [our] purpose" (Neta). In other words, the Open Clinic, in its
attempt to provide medical assistance to the asylum seekers, was
actually breaching its own principles by relieving the state of its
responsibility toward them. By the same token Ariel, PHR-IL’s
chairman, declared in a board meeting that “[.] we closed the Clinic
since it did not fulfill our principles. Not just because of the patient
load" (PHR-IL protocols). The Clinic’s closure was regarded “[.] as
an ultimate means of protest that will make clear to the Israeli
government that we cannot continue [fulfilling governmental
responsibilities] "(Rafi, former medical manager of the Open Clinic).
The Clinic closure served as a last resort to build up public pressure
and to call for government accountability toward asylum seekers.
Finally, the outbreak of infectious diseases within the asylum
seeker population demonstrated that PHR-IL, lacking appropriate
resources and capacities, was not only unable to offer a compre-
hensive response to asylum seekers’ healthcare needs; but it also
put the community’s health and the health of the clinic’s staff at
risk. The organization came to recognize that it was "irresponsible to
continue operating the clinic and to take responsibility for treating
chickenpox and measles" (Amos). A comprehensive intervention by
the public health authorities was the only appropriate response to
the growing incidence of communicable diseases. The PHR-IL
protocols reflect that the public health-argument tipped the
balance in favor of the Clinic’s closure and strengthened the orga-
nization’s demands for governmental action. Ittay confirmed:
"What convinced the physicians [at the board meeting] was not the
political argument, it was the medical one. And what convinced the
board in my opinion was the argument that we are having a public
health-issue here that we cannot deal with, that must be dealt with
by the Ministry of Health. This is what tipped the scale. It was later
that. political arguments entered [the discussion]."
As a whole, it seems that during the actual decision-making
process within PHR-IL the pressing practical and medical
challenges were most influential; whereas the political arguments
e including those relating to the Clinic’s role and the inherent
tensions - gained more importance during the closure and in the
subsequent discussions. Finally, in retrospect, the “refugee crisis”
also presented a veritable window of opportunity for PHR-IL: For
reasons related to Israel’s collective memory and self-concept,
refugees’ claims for healthcare entitlements are granted greater
legitimacy in the public and political discourse than those of
undocumented migrant workers (Willen, 2010). As summarized by
Neta: “What else do you need in this state than this word: ‘refugees’?”
Oded, former director of the migrant worker project and the Open
Clinic, explained that this particular health rights-discourse was
critical to the decision to close the Clinic: “This action only makes
sense when [.] you have something to say regarding policy [.]. Close
the clinic tomorrow morning and nobody will care. This is because
nobody thinks [undocumented migrant workers] deserve anything, in
contrast to asylum seekers where you have a claim.” Thus asylum
seekers’ alleged deservingness enabled PHR-IL to march the road of
political advocacy and demand that the state will provide for this
population’s healthcare.
Role and mandate of the Open Clinic
A central theme that emerged from our analysis of both inter-
views and protocols was the question of the Open Clinic’s mandate.
Divergent notions of the Clinic’s role e and in the larger picture of
PHR-IL’s role and identity e played a pivotal role in the discussions
on the Clinic’s closure. Our interviewees confirmed that this
dispute was not new, but part of an ongoing reflection process
within PHR-IL. Neta explained that even prior to the Clinic’s closure,
“all the time this question ‘what is the clinic?’” surfaced. “Is it supposed
to save lives or is it symbolic?”
Our analysis allows us to define several different, though
interrelated, dimensions that influence the operation of the Open
Clinic e humanitarian, political, legitimizing, symbolic, empower-
ing and organizational e some of which have explicitly been
addressed by PHR-IL. The Clinic was originally established as
a humanitarian venture that aimed to alleviate the suffering of
people who lacked access to healthcare.
"[S]everal physicians from the board said ‘Let’s establish [.]
a humanitarian clinic, a place where uninsured foreign workers
can be examined [.].’ It was definitely not clear that there was an
advocacy goal here [.] But [it] developed bottom-up, from the
work with individual cases.” (Oded)
The humanitarian provision of healthcare remained one of the
Clinic’s uncontested goals. But as additional dimensions emerged,
with the subsequent formulation of political objectives and the
connection of the Clinic’s activities to PHR-IL’s more political
activism, they gained importance vis-à-vis the humanitarian
element. Unanimously, our interviewees described that the Open
Clinic’s work has a political dimension: The Clinic is central to the
organization’s advocacy efforts to modify Israel’s current legislation
and immigration regime. Its encounter with the migrant pop-
ulations is both a critical source of information for the organiza-
tion’s political work and a tool for identifying the social structures
and mechanisms that impair migrants’ access to healthcare - causes
that should be addressed through political activism. Ittay reasoned:
“The Clinic’s first and central task [.] - even before the provision of
medical treatment – is to identify trends and problems related to
the entire topic of migration in Israel. [.] In general we are the first
to know [.] whether a group arrives from here or a group from
there, or when stories come up about the rape [of migrants] on the
way [to Israel] or things like that. [.] The Clinic is a sensor.”
However, the precedence that many PHR-IL members assign to
the political dimension today evokes heated objection among
others. Rafi, the Open Clinic’s medical director at the time, recalled:
 N. Gottlieb et al. / Social Science & Medicine 74 (2012) 839e845
“I [.] was pretty upset during the debate [on the Clinic’s closure]
as everyone [.] told me: Look, the Clinic’s purpose is not to treat
patients in first place, but to address the political problem of the
uninsured. [Its] purpose is to confront the Ministry of Health with
this subject, to show to the media that there is a problem [.] and in
the last place to treat patients. [.] From my perspective the role of
the Clinic [is] to treat patients, above all to give medical treatment
for people who have no other option."
Thus, while our interviewees agree broadly on the existence of
different facets of the Clinic’s work, their prioritization remains
a highly contested point, especially with regard to the political
versus the humanitarian dimensions.
Furthermore, our interviewees described the Clinic as playing
a legitimizing role for PHR-IL. In the Israeli context, in which human
rights organizations are considered a potential “fifth column” by
significant sectors of the political elite, the state apparatus, the
media and the public, the Clinic’s medical work functions as
a source of legitimacy, a tangible proof of the organization’s
commitment not only to preach lofty ideals, but also to practice
them by offering concrete assistance to marginalized populations.
Amos affirmed that the provision of medical aid as concrete and
uncontested ethical practice helps to legitimize PHR-IL’s political
work because “[b]eing physicians gives us special power, [.] our
agenda is medical [.] and our message is that medicine as a value is
uncontested [.]. So this is our power, [.] it makes a big difference
whether you do medicine or whether you talk about medicine.”
Thus several of our interviewees attributed to PHR-IL a special place
within the local NGO-environment, as its hands-on approach and
high social regard for physicians built an image of respectability
that some other NGOs lack.
The symbolic dimension implies that the organization sees the
Clinic also as a means of voicing solidarity with marginalized
populations. For many volunteers, their work in the Clinic is a way
to express their opposition to state policies and their commitment
to their collective memory as Jews. The empowering dimension
refers to the Clinic’s role in giving voice to marginalized pop-
ulations’ needs and perspectives; in providing a forum for the
development of common political activity with migrant
communities; and in increasing migrant workers’ and asylum
seekers’ power as a collective, political subject. Finally, the Clinic
plays also an organizational role: As a vehicle to recruit volunteers,
it increases the organization’s strength, broadens its support
and raises awareness through concrete experience in the field. It
“create[s] a framework for physicians to volunteer and through this
[experience] reach a different public. Because later on [.] with the
[acquired] information and experiences they can speak up and do
things; [one of the Clinic’s roles] is to facilitate these meetings.” (Ittay)
Differences in the interviewees’ prioritization of the Clinic’s
various roles reflect divergences in underlying paradigms and
modes of action: Greater emphasis on the Clinic as a provider of
medical services reflects a “new humanitarian” paradigm. An
instrumentalization of the Clinic in order to put political pressure
on the state points to an understanding of human rights that goes
beyond the liberal-juridical paradigm and addresses rights within
the socio-political context. A focus on the Clinic’s contribution to
PHR-IL’s status within Israeli society reflects awareness for the
complex socio-political questions concerning power and legitimacy
which characterize civil society.
PHR-IL’s role and mandate with regard to migrant healthcare
Our analysis revealed further unresolved tensions with regard to
the more general question of PHR-IL’s role as an NGO that works
with various excluded populations, such as Palestinians in the OPTs,
843
prisoners and detainees, and Bedouin-Arab communities. Some
interviewees reasoned that health rights activism on behalf of
citizen-populations clearly demanded a political approach e due to
their uncontested deservingness of state attention - whereas
migrants’ health issues would sometimes leave no choice but
a humanitarian response. Some conceptualized the organization’s
mandate as an equal combination of both medical practice and
political advocacy, describing both elements as complementary and
at the same time as important goals in their own right. Finally,
others emphasized that also regarding migrant healthcare, the role
of a human rights organization such as PHR-IL was primarily
political: “to tell, through the lens of health, the stories and difficulties
that migrants face in Israel, [.] to raise awareness, to suggest alter-
natives and to promote solutions [.]. Our role is to speak through the
health lens on issues related to [.] the immigration regime.” (Ittay)
Neta suggested that the provision of medical aid must be subor-
dinated to PHR-IL’s more political activism even though “the first
thing I want to do is give them [medical] treatment [.], but I know it
obstructs [a political solution]. So if I had to choose [.] then PHR-IL
should invest all its energies in the struggle for structural change.”
By the same token, Ariel emphasized at a board meeting that “our
principle [goal] is not to treat the destitute, but [to ensure] that people
will not be destitute” (PHR-IL protocols).
Interactions between medical humanitarianism, human rights and
political advocacy
A great variety of views existed within PHR-IL regarding the
interaction amongst medical/humanitarian, human rights and
political perspectives. "To put [the central question] bluntly,” Oded
asked “Is the clinic solving a problem for the state, soothing some
policy problem we want to solve? Or does it point to the existence of
a problem, thus helping to find a solution?”
Few PHR-IL members reconciled these competing paradigms
and the resulting paradoxical situation in which “[t]he goal of the
[advocacy] project is to close the clinic, [whereas] the goal of the clinic
is to treat patients”. They confirmed PHR-IL’s dual role in doing
"serious clinical work alongside serious advocacy" (staff member,
PHR-IL protocols). Many others perceived the tensions between
humanitarian action, human rights and political advocacy as
problematic, mainly due to the difficulty in maintaining the polit-
ical mandate over time, alongside the medical practice. Ittay
explained that “[t]his balance is hard to keep [because] each one pulls
in a different direction. The clinic and the physicians want to provide
medical treatment [.] even though they know all the ideology behind
it.” Nonetheless, he held, it was impossible to abandon one of the
three facets because the power of the Clinic’s work lies in the
interaction and mutual enrichment of the medical/humanitarian,
the human rights and the political mode of action:
“The role of PHR-IL should be political, but it cannot exist without
the humanitarian aspect [.]. We are not perceived as just another
political organization that has no contact with the field and talks
a lot of hot air [.]. The clinic is safeguarding us. It backs us. It gives
us the power to say: ’Listen, we do not only talk, we act as well’.”
Others argued that the humanitarian practice should be kept
separate from the political struggle. Rafi, for example, expressed
frustration over the, in his view, pointless closure of the Clinic: “If you
want to protest in front of the government offices you can do it. If you
want to take hundreds of foreign workers or refugees [.] to the door-
steps of an emergency room [.] you can do it. Why do you need to
simultaneously close the Clinic?” He argued that such step was not only
unnecessary but counterproductive because the political struggle
could have been fought more effectively by keeping the Clinic open
while demonstrating against the lack of governmental involvement.
844 N. Gottlieb et al. / Social Science & Medicine 74 (2012) 839e845
Above dilemma made PHR-IL staff and members confront
thorny questions of responsibility: "Why do we take responsibility
for their care? [.] Because this is what happens today: [.] We are
leading fundamental political debates about the treatment of migrant
workers, but [.] the individual cancer patient who needs treatment
now - who takes responsibility for him? We do" (Rafi). As a human
rights organization, PHR-IL holds the State accountable for asylum
seekers’ healthcare. But with the operation of the Open Clinic it
enters into a relationship with patients and their communities that
inevitably entails commitments that cannot be easily withdrawn.
Rafi conceded: “We made ourselves responsible and we played into
the hands of the government [.]. Now they can with clear conscience
[.] even refer patients to us.” This self-critical assessment suggests
that the Open Clinic ultimately fell into the “humanitarian trap” of
relieving the State of its responsibilities.
As mentioned above the Clinic’s political struggle rode on
a wave of public support that is related to a notion of asylum
seekers’ greater deservingness as compared to undocumented
migrant workers. Our interviewees described divergences between
this notion and their personal conception of health rights, which
puts entitlements into a broader socio-political context. This view
was expressed, for example, by Neta:
“[To express] my political attitude in this regard - that it is actually
the West that pushes people from Third World countries to migrate
here - is like talking to the walls. Nobody in the Ministry of Health
would say ‘Ah, we have oil deals with Nigeria, so we have to give
[this Nigerian patient] treatment.’ [.] For the treatment of a Fili-
pina who has overstayed her visa or a Nigerian who gets cancer
after 13 years - I did not have anybody to turn to with such cases
[.]. But [regarding asylum seekers] I have more of a basis to turn to
the State, speak its language and say: ‘You have to give this person
treatment’. [.] Israel has signed the refugee convention, not the
migrant worker convention.”
Interviewees were aware that such broader concepts were
difficult to convey to both the authorities and the general public.
They explained that “it was easier to hand over responsibility for
refugees and not migrant workers. But these are political consider-
ations: that it is easier to wave the flag of the refugees than that of
migrant workers. No doubt. Me personally, of course, I do not see any
difference” (Rafi). They thus explicated the use of a legalistic health
rights-discourse as a strategic choice that enabled PHR-IL to win
broader public support and to beat the authorities with its own
juridical weapons - at the price of narrowing down its health
rights-discourse.
Discussion
Our case-study has provided a close look at a concrete situation
in which an NGO takes action on behalf of a population group that
lacks access to basic healthcare. It thus allows for a better under-
standing of the context-specific forms in which different groups’ -
such as (documented and undocumented) migrant workers’, refu-
gees’ and asylum seekers’ - “deservingness” is framed: whether in
terms of humanitarian healthcare provision, legal claims to indi-
vidual rights, an overtly political struggle against exclusion - or the
interaction among all three paradigms and modes of action. PHR-IL
serves as a pertinent test-case: Created as an organization that
combined “neo-humanitarian” practices (such as a mobile clinic
operating in the OPTs) and “classic” human rights action (such as
publishing reports and appealing to the courts) it developed and
broadened its definition of health to include social determinants;
and it expanded its conceptualization of human rights so as to
ground its rights discourse on a political vision of comprehensive
social justice. This evolution, however, has not made any previous
dimension disappear. The three dimensions are simultaneously
present, albeit based on different (sometimes contradictory) claims
of “deservingness”, engendering conflicts concerning which claim
will supersede as the organizing principle. The crisis discussed in
our case-study has put these conflicts on the table and thus opened
a window of opportunity for a rich internal debate.
How does our case-study help to illuminate the role of NGOs
involved with migrants’ access to healthcare? Israel, where the
combination of an exclusionary structure of citizenship and the
neo-liberalization of the welfare state strongly reduce the bound-
aries of “deservingness”, provides an example of a context in which
NGOs play an increasing role not only in advocating on behalf of
migrants but also in providing services. As we can appreciate from
our case-study, NGOs get caught between a humanitarian
approach, a legalistic conception of rights, and their political
notions of rights as part of an encompassing vision of social justice.
Miraftab’s paper “Flirting with the Enemy” discusses the challenges
faced by NGOs and the risk of reproducing relationships of subor-
dination (1997). Our case-study exemplifies how strategies adopted
by human rights NGOs perpetuate humanitarian practices and
individualistic/legalistic conceptions of rights even in an organi-
zation that adopts a more socio-political approach. PHR-IL appeals
to images of common humanity that form the basis of humani-
tarian practice; it tactically uses a legalistic rights discourse in its
advocacy; and it grounds its claims for state responsibility for
asylum seekers’ health in Israel’s ratification of binding interna-
tional legal agreements - even though such narrow views do not
reflect PHR-IL members’ “true” conceptualization of the right to
health. We thus agree with Willen’s finding that NGOs “employ”
health rights claims as well as other “idioms of social justice
mobilization strategically” (2011), including the willingness to
“tune down” their health rights-discourse to the authorities’ level.
Thus ultimately, human rights and neo-humanitarian NGOs may
converge at the level of discourse used, as well as at the level of
actions taken. However, the choice of discourse is more than
a strategic act. It reflects the persistent strength of traditional
individualistic conceptions of rights: conceptions that limit the
scope of “deservingness”. PHR-IL, like many other NGOs around the
world, tends to resort too quickly to the legal track, thereby
reproducing a limited individualistic notion of health rights at odds
with the broader health rights approach it aims to promote.
A reflection on the tensions between the three conceptions of
a right to health helps us to scrutinize in more general terms the
relationship between NGOs and the state. Even when addressing
social rights, many traditional human rights organizations consider
themselves as exterior and opposed to the state. Likewise “new
humanitarian” organizations, who regard themselves as external
(though not always opposed) to the state, whether as providers of
humanitarian help and witnesses of state’s violence, or as providers
of services that the neo-liberal state does not deliver. However,
a more political understanding of human rights grounded on the
idea of social justice implies a more nuanced relationship with state
agencies, since the implementation of equal social rights requires
an active role of the state. Thus, the conflictual interplay between
the three different levels, as exemplified in our case-study, opens
the stage for different possible models of relationship between
NGOs and state agencies. A conceptualization of these models may
be facilitated by a human rights-concept grounded on a “universal
right to politics” as proposed by Balibar (Balibar, 2004: 321): A
notion of the rights of man as entrenched, historically and theo-
retically, in the right to actively participate as members of the
political community. From this perspective NGOs are not
completely external to the state; rather is the state the arena where
they engage in social conflicts e.g. around “deservingness” for
health.
 N. Gottlieb et al. / Social Science & Medicine 74 (2012) 839e845
The coexistence of different health rights discourses and practices
stems from the fact that “the right to health” is a concept in constant
change and “[i]ts interpretation and implementation [is]. shaped by
local attitudes both toward health . and toward human rights.”
(Willen, 2010) Even within health rights NGOs we find lack of clarity
and agreement on the exact meaning of this right and on related
claims for deservingness. Inasmuch as these ambiguities and
contradictions remain unspoken, this “curious inattention to right to
health claims has [.] impeded understanding of the complex relation-
ships among different idioms of social justice activism, including, for
instance, those identified as human rights or humanitarian” (Willen,
2011). Our analysis suggests that within the current Israeli context
(framed by an ongoing occupation of the Palestinian territories,
exclusionary structure of citizenship and neo-liberal recommodifi-
cation of the welfare state) human rights NGOs are torn between the
pressures to support neo-humanitarian provision of services, classic
human rights advocacy and a more political rights-based approach to
health and social justice. In this situation, the very act of reflecting
upon and discussing these tensions - including the relations among
NGOs, the state and migrant communities - bears great importance in
its own right and is invaluable in the effort to find the most appro-
priate solutions for situations of crisis. Our study furthermore
exemplifies how such crisis situation can be seized as an opportunity
to engage in a re-conceptualization of the right to health. Firstly, we
claim that rights should be understood not as an individual pre-
political entitlement but as a right situated within the political
sphere, as an evolving expression of the universal right to politics or,
in Hannah Arendt’s terms, “the right to have rights” (Arendt, 1951).
Secondly, we should understand health not only as a reflection of bio-
medical realities, but as the result of complex, always political
interactions between various levels, including the distribution of
resources and access to services. This re-conceptualization of the
right to health will allow the contextualization of humanitarian
practices, human rights and political advocacy practices within
a political understanding of the right to health as grounded on
a universal, egalitarian notion of social justice.
Acknowledgments
We want to thank Sarah S. Willen very much for her initiative for
and tireless work on this special issue. We are indebted to Sarah as
well as to Na'amah Razon and three anonymous reviewers for their
thoughtful comments on earlier drafts of our manuscript. And we
want to warmly thank the PHR-IL staff and members for their
participation and cooperation in this study.
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