Since October 7, the world's eyes have been on the Israel-Hamas conflict, but a small band of humanitarian workers have been pulled directly into the fray.
Among them is Paul Spiegel, director of the Center for Humanitarian Health at Johns Hopkins University, who in late 2023 was deployed to Amman, Jordan, and Cairo, Egypt, as a strategic health advisor to the United Nations Relief and Works Agency (UNRWA). He spoke with Think Global Health in late December from the Netherlands about his personal and professional views as a person of Jewish heritage with decades of humanitarian experience in conflict zones.
Last week, Israel accused a dozen UNRWA employees of being involved in the attacks. The agency promptly fired nine of them. Spiegel wrote afterward via email that he was "saddened and horrified" by the reports and urged the agency to "ensure that all allegations are transparently investigated, and anyone found to have participated in the attacks must be held responsible to the fullest extent of the law."
He pointed out, though, that UNRWA employs 13,000 people in Gaza, and that it was not fair to hold the entire organization responsible for the actions of a few, no matter how horrific and unconscionable their actions.
"When I was deployed with UNRWA, those I worked with in the health team were professional and exemplary throughout. I believe the work that they have done has saved thousands of lives."
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It's always important to respect the four humanitarian principles of humanity, neutrality, impartiality, and independence
Think Global Health: What in your upbringing sparked your interest in work that as an adult would take you to conflict zones around the world?
Paul Spiegel: Most people come into the humanitarian world by chance. I grew up in a middle-class area of Toronto. It was a very easy, loving childhood. But I felt I always wanted a little bit more.
When I was maybe 14 years old, I was reading Time Magazine about a French doctor on what at that time was the Thai-Cambodian border. It was the beginning of Doctors Without Borders (Médecins Sans Frontières).
I just looked at the story and said, "Gosh, that's what I'd like to do."
Think Global Health: You studied political science as an undergraduate—how is that relevant to humanitarian health?
Paul Spiegel: In any humanitarian setting, what we do is public health, but the core of everything is politics and power. I don't know whether [studying political science] was deliberate at the time, but I knew I was interested, and it has held me in very good stead.
It's helpful during all of these emergencies—and I've been in most of the big emergencies in the last 30 years—to understand the culture and political dynamics, how people are thinking. It dramatically affects the space where humanitarians can respond.
Think Global Health: When you are part of a humanitarian response, what is your posture toward geopolitics?
Paul Spiegel: It's always important to respect the four humanitarian principles of humanity, neutrality, impartiality, and independence.
I always do my best to not become involved politically, but I think it's extremely important to understand the situation. It can help me achieve my aims yet remain independent and neutral and impartial.
Think Global Health: What's your relationship with the Israel-Palestine conflict and the peoples involved there?
Paul Spiegel: I'm a Canadian of Jewish background, not practicing. My junior year, in 1984, I studied at Hebrew University in Jerusalem. On my floor in the dormitories, I had Israelis who had just finished their military service; I had Palestinians; I had Ethiopian Jews who had just come over from Operation Moses. I was always inquisitive, so I tried to befriend all those people. I really tried to understand everyone's point of view, and I read a lot on both sides. It was such an important year for me and one of the most enlightening years I've ever had.
That was a really different era. I had hoped that there would be a two-state solution and fairness and equity for all involved. From my point of view, even then, Israel's occupying another land was not going to be feasible in the long term, nor was it ethical. Given the Jewish background and the history of the Holocaust, I thought that isn't something that they should be doing. There was also discrimination against the Palestinians. It wasn't as overt as it is now.
There were a lot fewer settlements at that time. It would have been much easier then to have a two-state solution and that's where I assumed it would go. Since then, everything has become much more polarized and much more complicated.
Think Global Health: Tell us about your recent stint in the region.
Paul Spiegel: I've been working on this since October 7, but from November 23 until December 21 I was deployed with UNRWA. I worked with them to set up incident management systems, [to monitor] diseases of epidemic potential, trying to understand the data and looking at different scenarios. For example, right now the internally displaced people in Gaza are primarily living in schools that are serving as shelters, but we're very concerned that eventually those searching for shelter and safety may take over health centers, and those centers [will cease] functioning.
[Before the recent outbreak of conflict,] UNRWA had emergency operations plans, but they were based on what had happened in the past. They had 53 schools designated as shelters to hold around 2,000 people each—but suddenly you have 99 shelters with an average of 15,000 people.
The scale, the intensity, I don't think anyone had envisaged [that].
They had 53 schools designated as shelters to hold around 2,000 people each—but suddenly you have 99 shelters with an average of 15,000 peoplePaul Spiegel
Think Global Health: What are the similarities or differences between your latest deployment to the region and other emergencies in which you've recently worked, such as Afghanistan and Ukraine?
Paul Spiegel: Every humanitarian emergency is unique. The Gaza Strip is extremely small and very, very densely populated. In most other humanitarian emergencies, people can flee within the country or outside of the country. There's an escape valve. Israel has said there are certain safe zones, but in reality that hasn't been the case.
The siege aspect makes it extremely difficult, if not impossible, for humanitarians to respond adequately. Suddenly, at the beginning, you had no food, water, electricity, fuel, medicines. Eventually there was a slight increase both through the Rafah crossing [between Gaza and Egypt] and now Kerem Shalom, another border point, has opened. The amount of goods needed is just massive. UNRWA has 95 shelters with more than 1.4 million people. Toilets and showers are very few, and therefore the water and sanitation situation is bad.
You're not able to send people in, so you're relying on Gazan staff who are there and were already working. UNRWA has by far the largest footprint: it had 13,000 employees in Gaza, the majority of whom were teachers, but they had only 1,000 health-care workers.
But they and their families are also being displaced and have to wait in queues for water and food. It's heroic, what they're trying to do, but extremely difficult.
We have to listen to them, too. You don't just start your day off with a list of tasks; instead you say, "How are you? How's your family? Where are you now? Do you have enough food? How can we help?"
Think Global Health: A little bit more intimate.
Paul Spiegel: Definitely more intimate. More personal. My second day in Cairo, we went to visit a UNRWA health-care worker. She and her family were severely injured in a bombardment. She was severely burned. Her husband was okay. She had five children; two were killed. One was severely burned; one had a broken femur and needed an external fixation.
I am a physician so you are exposed to these sorts of things. You try as much as possible to stay objective and apolitical and concentrate on the humanitarian component of what you're doing. Always trying to remember [the October 7 attack on] Israel was such a seismic shock.
It's really hard to strike this balance. Because currently the need is more in Gaza. Israel has a strong functioning health-care system. They don't need my support in the same way that Gaza does. But I feel equally compelled to help Israeli civilians.
It's not taking sides at all. It's just helping whoever needs help wherever they are.
Think Global Health: Does the unique history of the Jewish people and your connection to them change things at all?
Paul Spiegel: No. I've been doing this for a long time, and I don't think on a personal level it affects my actions whatsoever. I have no idea whether the people I was working with knew my religious background.
What was different in this situation is that some friends, family, and colleagues see it differently. It was surprising that they would be critical of my wanting to go and help civilians in Gaza.
A colleague who doesn't know me said, "I'm embarrassed to be your colleague." Friends that I hadn't heard from in 30 years criticized me for doing something like this.
To me, it's so apolitical. But people are divided so much on this; you're either on one side or the other.
Think Global Health: Are there always two sides?
Paul Spiegel: At least two, often more. For example, after the Rwandan genocide in 1994, I was in Eastern Zaire [now the Democratic Republic of Congo] as a medical coordinator for two refugee camps. Certainly the people we were helping were unarmed civilians, but it is likely that some were Interahamwe who had committed crimes and were now in these camps. I never knew for sure.
In 1992 when I was the medical coordinator for Kakuma refugee camp in Kenya, the Sudanese People Liberation Army were clearly there. I never saw them. I never saw anyone with guns, but a lot of young men were there, so the group was probably using that camp.
When you look at Ukraine and Russia, for example, one side is clearly the aggressor. Whether it be sexual violence or not treating prisoners of war correctly, that often happens on both sides—just not necessarily in the same proportion.
I will always move toward protecting civilian lives whenever possible
Think Global Health: And you're looking at people always as human beings before thinking about their past.
Paul Spiegel: As long as they're unarmed combatants. It's very difficult when people have taken off their uniforms to know who they are. This is a bit of what Israel's dealing with now, talking about human shields, Hamas fighters mixed in with residents—[similar to how] the Interahamwe from Rwanda were mixed in with civilians. Do you bombard a whole apartment building for one Hamas militant? Do you stop giving food aid to 10,000 women and children because a couple Interahamwe are in the camp? These are difficult decisions. I'm not pretending this is an easy situation. But I will always move toward protecting civilian lives whenever possible.
Think Global Health: Social media has become a preeminent way of communicating about the conflict. How is it affecting things?
Paul Spiegel: I find it incredibly negative because, first, it's a lot of pictures and videos. [It doesn't convey] the background of international humanitarian law or the history of a people. Number two, there's a tremendous amount of misinformation. We need to get away from the soundbite, headline, picture, or video. . . . People need to read and think a little bit more about the complexities of the situation.
Think Global Health: Is there anything left out of the dominant news coverage that you think people should understand?
Paul Spiegel: Yes. The attacks on health care are some of the most extreme ever documented in a short period. The hospitals that have been attacked, the ambulances. . . In international humanitarian law, two key concepts are proportionality and discrimination. Schools and hospitals have a special status; it doesn't mean that you can never attack them, if they're dual usage—meaning one of the sides believes the other side is using them for military purposes—but it does mean you need to take the most care if this is the case to protect patients and civilians.
What's astonished me is the amount of destruction, sometimes apparently indiscriminate, and the brute force as opposed to a more surgical way of avoiding civilian deaths. I don't pretend to be a military strategist so I'm not saying by any means "this is how militarily they should do it." But there need to be ways to examine how to dramatically reduce the numbers of civilian deaths and injuries.
EDITOR'S NOTE:This interview was conducted via Zoom and has been condensed and edited for clarity.