The academic community must develop a strong position to shield journals, their editors, and staff, against pressure to enforce censorship.
In March 2020, The Lancet published a letter we wrote alerting the medical community to the dangers of a covid-19 outbreak in the Gaza Strip. We warned that the pandemic had “the potential to devastate one of the world’s most vulnerable populations.”  Since then, this fear has become reality and Palestinians in the Gaza Strip have now endured a fifth largescale Israeli military assault that has killed 256 Palestinians, including 66 children, injured nearly 2,000, and internally displaced some 107,000 people. [2,3]
As we highlighted in our letter, decades of structural violence targeting Palestinian people have brought Gaza’s healthcare system to the brink of collapse.  A densely populated area, the majority of Palestinians in the Gaza Strip are refugees denied their right of return since 1948.  Meanwhile, Israel’s illegal closure and blockade of Gaza since 2007, amounting to collective punishment, have meant that supplies for covid-19 testing, treatment, and vaccination have been severely limited. [6,7]
Although structural racism has increasingly been recognised worldwide as exacerbating the impacts of covid-19, the publication of our letter was met with what Richard Horton, the editor-in-chief of The Lancet, informed us was a threatened boycott of the journal.  Certain physicians from the United States and elsewhere had demanded our letter’s removal. Previously, Horton informed us, there had been a similar “sanctions” campaign against The Lancet for publishing a letter in 2014 deploring the morbidity and mortality resulting from Israeli state violence against Gaza’s besieged Palestinians. [9-10] According to Horton, the ordeal that followed took a “traumatic” personal toll on The Lancet’s employees. Subsequently, The Lancet published a special edition on Israeli healthcare that we believe disregards the historical and political forces impacting Palestinian health outcomes. [11,12] The Lancet’s publication seemed to stand as a warning to anyone who dared address Palestinian health consequences of Israel’s action, which are widely recognised as amounting to war crimes and crimes against humanity. 
The Lancet, we were later told, could not sustain yet another campaign of this nature and, within three days, our letter had been removed from the journal’s website. To date, formal retraction of academic articles has been reserved for papers with “pervasive error, non-reproducible research, scientific misconduct, or duplicate publication.”  None of this applies to our letter. In our view, The Lancet’s editorial removal of our letter constitutes a dangerous new precedent, in which an already published article, that is later deemed politically unpalatable by extra-editorial forces, ends up in an academic “no-man’s-land”—not formally retracted, yet unavailable from the journal itself.
By allowing powerful external political interests to overrule editorial judgement and policies, the removal of published articles in peer-reviewed journals deals a massive blow to academic freedom. Sadly, this is only the elite tip of the academic freedom iceberg. What of all Palestinians, who—because of Israel’s ongoing occupation—cannot even access the resources necessary to engage in the free exchange of ideas or share their lived reality? 
Our latest experience of censorship stands at odds with The Lancet’s long-standing commitment towards advancing Palestinian health, in particular through the leadership of Richard Horton.  In 2009, The Lancet published a series of reports on health in the occupied Palestinian territory. Here, Horton drew attention to “The prison-like cage built around Gaza, the daily humiliations for women, children, and workers passing through checkpoints, the paralysis of the West Bank caused by occupation, [and] the obstacles imposed on communities trying to build schools, clinics, and homes for their children.”  This Lancet series was followed by the establishment of the “Lancet Palestinian Health Alliance” (LPHA), which has continued to organise invaluable, annual scientific conferences in the region. LPHA has published hundreds of abstracts from Palestinian and international researchers and provided a “scientifically sound platform for advocacy, awareness, and action around health” in Palestine. 
Meanwhile, the cohort of doctors attempting to actively threaten and censor any critical writing on Palestinian health today enjoy respect in their fields. They come primarily from settler colonial societies, including Israel, the United States, Canada, and Australia, and are regularly granted platforms in academic journals to “balance” out the truth about Israel’s oppressive policies. [19,20] The logic is that there are “two sides” to any story involving Palestinian health, and thus equal weight must be given both. What this approach disregards, however, is the profound power differential that inevitably sustains settler colonial myth while concealing the experiences of the colonised. But with medical school curricula increasingly including social medicine and structural competency, these presumptions of “balance” are no longer holding.  The ongoing “epistemicide” of Palestinian history and present realities has an urgent remedy: we must actively challenge and correct the dominant narrative by promoting subaltern and decolonial narratives.  Expanding discourse in academic medical journals on structural racism as a root cause of health inequities is a long-needed step in the right direction. 
The Lancet did not take this route, however. A full six months after we were censored, it published a letter in reply to our deleted correspondence. Authored by Zion Hagay, the Chair of the Israeli Medical Association—an institution whose complicity in torture is well-documented—the response to our piece failed to challenge any of our arguments beyond reference to a now repeatedly criticised UN comment about close coordination between occupier and occupied. [24-26] His only other reference was to our vanished letter, with a link that leads nowhere. As we wrote in a reply to Hagay: “While our Correspondence may no longer be viewable on The Lancet’s website… the desperation that its forced disappearance implies and the easily disproved propaganda contained within his published response, suggest that fewer and fewer health professionals will be fooled going forward.” Our authors’ reply was rejected by The Lancet.
Yet, the story did not end here. We submitted a commentary to another Lancet journal whose editor-in-chief informed us that the Lancet group has recently been subjected to “very damaging boycotts” when publishing content critical of Israeli policies and practices without a “counterpoint from the Israeli perspective.” Since an attempt to solicit such a counterpoint had proved unsuccessful, the publication of our commentary could not go ahead. We feel that the lessons from our experience are clear: the Palestinian narrative can be voiced only when it is simultaneously disavowed, while the Israeli narrative—in this case the response from Hagay—can stand alone. This remarkable double standard confirms that so-called “balance” policies protect everyone but the oppressed.
Holmes et al. have observed that “Clinicians are uniquely positioned to respond to the social, political, and economic structures affecting our patients’ health.”  Yet, this new form of censorship perpetuates misdiagnosis of the root causes of Palestinian ill health, limiting clinicians’ ability to respond and advocate effectively. In our opinion, imposing censorship in academic journals as a direct result of external threats is a dangerous and totally unacceptable path. An urgent task for the academic community is to develop a strong position that can shield journals, their editors, and staff, by pushing back against the physicians and scientists who pressure journals to enforce censorship.
Despite ongoing silencing and a dedication to illusory “balance” in publishing on Palestine, health professionals are increasingly mobilising against structural violence targeting the Palestinian people as a whole.  We are encouraged by calls for decolonisation of scholarship on Palestine, evidence-based solidarity, and academic resistance to settler colonialism and apartheid.  As the pandemic continues to expose deep-rooted structural health inequities with devastating human consequences, it is imperative not only to address infringements on academic freedom, but to challenge the colonial power dynamics still prevailing in academic medicine.
Rania Muhareb is a Hardiman PhD Scholar at the Irish Centre for Human Rights at the National University of Ireland, Galway, a consultant with the Palestinian human rights organisation Al-Haq, and a Policy Member of Al-Shabaka – The Palestinian Policy Network.
Bram Wispelwey is a co-founder of Health for Palestine and medical director of 1for3. He teaches at Brigham and Women’s Hospital and at Harvard Medical School.
Mads Gilbert is a specialist in anaesthesiology, senior consultant at the University Hospital of North Norway, and professor emeritus at the Arctic University of Norway in Tromsø. He has authored the books Eyes in Gaza (2009) and Night in Gaza (2014). Since 1981 he has worked with solidarity medicine in Lebanon and occupied Palestine and co-founded The Norwegian Aid Committee (NORWAC).
Competing interests: none declared.
1. David Mills et al, “Structural violence in the era of a new pandemic: the case of the Gaza Strip” (The Lancet, 27 March 2020) <https://www.sciencedirect.com/science/article/pii/S0140673620307303>.
2. OCHA oPt, “Response to the escalation in the oPt | Situation Report No. 1 (21-27 May 2021)” (27 May 2021) <https://www.ochaopt.org/content/response-escalation-opt-situation-report-no-1-21-27-may-2021>
3. OCHA oPt, “Gaza Strip: Escalation of hostilities 10-21 May 2021” (22 May 2021) <https://www.ochaopt.org/content/gaza-strip-escalation-hostilities-10-21-may-2021>.
4. OHCHR, “COVID-19: Israel has ‘legal duty’ to ensure that Palestinians in OPT receive essential health services – UN expert” (19 March 2020)<https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=25728&LangID=E>.
5. See, for example, Francesca P Albanese and Lex Takkenberg, Palestinian Refugees in International Law (OUP 2020) 342-375.
6. Geneva Convention Relative to the Protection of Civilian Persons in Time of War, 12 August 1949, 75 UNTS 287, Article 33.
7. Matthias Kennes, “Palestine is bearing the brunt of vaccination inequalities” (BMJ, 1 April 2021) <https://blogs.bmj.com/bmj/2021/04/01/palestine-is-bearing-the-brunt-of-vaccination-inequalities/>.
8. AHA, “Structural racism as a public health crisis” (14 November 2020) <https://sessions.hub.heart.org/home/video/21203056/structural-racism-as-a-public-health-crisis?utm_source=Scientific+Sessions&utm_campaign=3d57b385fc-EMAIL_CAMPAIGN_2020_12_01_09_52&utm_medium=email&utm_term=0_6e5f148efb-3d57b385fc-48148289>
9. Julio Rosenstock et al, “Bringing closure: towards achieving a better understanding of Israel” (The Lancet, 31 July 2019) <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31760-X/fulltext#%20>.
10. Paola Manduca et al, “An open letter for the people in Gaza” (The Lancet, 23 July 2014) <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61044-8/fulltext>
11. The Lancet, “Health in Israel” (The Lancet, 8 May 2017) <https://www.thelancet.com/series/health-in-israel>.
12. Michelle Morse and Bram Wispelwey, “Health equity in Israel” (The Lancet, 10 February 2018) <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32171-2/fulltext>.
13. See, e.g., UN Human Rights Council, Report of the detailed findings of the independent international Commission of inquiry on the protests in the Occupied Palestinian Territory (18 March 2019) UN Doc A/HRC/40/CRP.2 <https://www.ohchr.org/EN/HRBodies/HRC/RegularSessions/Session40/Documents/A_HRC_40_74_CRP2.pdf>.
14. Diane Scott-Lichter and the Editorial Policy Committee, Council of Science Editors, White Paper on Promoting Integrity in Scientific Journal Publications (3rd edn, Wheat Ridge 2012) <http://www.councilscienceeditors.org/wp-content/uploads/entire_whitepaper.pdf>.
15. Judith Butler, “Israel/Palestine and the paradoxes of academic freedom” (Radical Philosophy, January-February 2006) <https://www.radicalphilosophy.com/article/israelpalestine-and-the-paradoxes-of-academic-freedom>.
16. Bram Wispelwey et al, “Permission to Narrate a Pandemic in Palestine” (August 2020) XXVII  Middle East Policy <https://mepc.org/journal/permission-narrate-pandemic-palestine>.
17. Richard Horton, “The occupied Palestinian territory: peace, justice, and health” (The Lancet, 5 March 2009) <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60100-8/fulltext>.https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60100-8/fulltext
18. Ibid; Graham Watt et al, “Progress of The Lancet Palestinian Health Alliance” (The Lancet, 5 December 2013) <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62233-3/fulltext>.
19. Omar Karmi, “The Lancet censors Gaza health letter after pro-Israel pressure” (The Electronic Intifada, 1 October 2020) <https://electronicintifada.net/content/lancet-censors-gaza-health-letter-after-pro-israel-pressure/31371?utm_source=EI+readers&utm_campaign=758cda532e-RSS_EMAIL_CAMPAIGN&utm_medium=email&utm_term=0_e802a7602d-758cda532e-299169613>.
20. Orly Manor et al, “Palestinian and Israeli health professionals, let us work together!” (The Lancet Global Health, 1 September 2020) <https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30324-7/fulltext>.
21. Jonathan M Metzl and Helena Hansen, “Structural competency: theorizing a new medical engagement with stigma and inequality” (Social Science and Medicine, February 2014) <https://pubmed.ncbi.nlm.nih.gov/24507917/>.
22. Budd Hall and Rajesh Tandon, “Decolonization of knowledge, epistemicide, participatory research and higher education” (2017) 1 Research for All 6-19 <http://unescochair-cbrsr.org/pdf/resource/RFA.pdf>.
23. Zinzi D Bailey et al, “How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities” (NEJM, 16 December 2020) <https://www.nejm.org/doi/full/10.1056/NEJMms2025396>.
24. Derek Summerfield, “The campaign about doctors and torture in Israel five years on” (BMJ, 9 July 2014) 349 <https://www.bmj.com/content/349/bmj.g4386>.
25. Zion Hagay, “Israeli aid to the West Bank and the Gaza Strip during the COVID-19 pandemic” (The Lancet, 26 September 2020) <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31968-1/fulltext>.
26. Tamara Nassar, “Israel turns UN praise into propaganda” (The Electronic Intifada, 2 April 2020) <https://electronicintifada.net/blogs/tamara-nassar/israel-turns-un-praise-propaganda>.
27. Seth Holmes et al, “Misdiagnosis, Mistreatment, and Harm — When Medical Care Ignores Social Forces” (NEJM, 19 March 2020) 382 1083-1086 <https://www.nejm.org/doi/full/10.1056/NEJMp1916269>.
28. APHA, “Palestine Health Justice Working Group Statement on Spring 2021 Attacks on Health in Palestine – Signatures of Support from Public Health Professionals” (accessed on 21 May 2021) <https://docs.google.com/forms/d/e/1FAIpQLSdgvrw_2ux8wBExdI1rDVUuPSeD_rxxiOkNHys60pTGqamdwA/viewform?fbclid=IwAR0cWsFg8uNzDV99onq2jGtOeozud6ddsPIiG6XLR_b_VrY4HnY1huP___U>.
29. Palestine and Praxis, “Open Letter and Call to Action: Scholars for Palestinian Freedom” (accessed on 21 May 2021) <https://palestineandpraxis.weebly.com/>.