July 21, 2011
Professor Charles Warlow,
The abstract published recently (July 5th 2011) on-line by the Lancet entitled “Childbirth at checkpoints in the occupied Palestinian territory” was read with interest and concern. The article purports to present data that the delay at checkpoints for mothers “travelling to give birth in hospital” in the 8 year study period (2000-2007) resulted in 69 births, 35 infant deaths and 5 maternal deaths. It concludes that the data is consistent with the “crimes against humanity,” and that the issue should be pursued in the International Courts.
Unfortunately, serious question must be raised both as to the validity of these data, and to the public health implications, let alone the legalistic interpretations of the author. Standards of epidemiologic and public health studies require a clear definition as to the source of the raw data. There needs to be appropriate population statistics so that proper calculations of the magnitude – if any – of the problem can be made. Clear analysis needs to ensure that inappropriate and confounding biases and variables are minimized. Regrettably, the aforementioned study fails on all these criteria. To quote the author (Shoaibi) in the methodology section “the study was undertaken through desk research and legal case analysis with data from… the International Criminal Tribunal for the former Yugoslavia and the International Criminal Court for Rwanda”. One must question the public health relevance of data from Yugoslavia and/or Rwanda in analyzing a phenomenon in Palestine. There is no mention of data sources and analysis from the local (Palestine) site. It is thus difficult to understand the relevance of legal analysis and opinion per se when one is purporting to present a public health outcome that is still unsubstantiated.
Turning to the substance of the article, one must raise questions as to the accuracy of some the data actually presented. The author cites (source not given) the statistic that the percentage of home births rose from 8% in 1999 to 33% in 2002 as measure of the impact of the checkpoints. The basic relevance of these data is questionable as the study period is 2000-2007. Furthermore, these data are contradicted by statistics published in the Lancet in 2010. In a study by Fujiya et al (Lancet on-line July 2nd 2010) data from the Palestinian Ministry of Health (2005) and the Palestinian Demographic and Health Survey (DHS) (2004) are cited. Home birth rates were as follows: 2000- 8%; 2001 -8%; 2002 -15% “reflecting Israeli military action”; 2003 -8%; 2004 -5%; 2005 -6 %. Surely these official Palestinian Health data belie Shoaibi’s data and do not support a conclusion that any continued checkpoint activity after 2002 has led to an increase in home births. If anything, on the contrary, there has been a decrease!
Shoaibi presents further unsubstantiated data as to the number of pregnant Palestinian women who were delayed at checkpoints. From a public health point of view without knowing the stage of pregnancy and the condition of the mothers such a statistic is meaningless. In addition, public health analysis of a phenomenon needs to have a reference point of the total the population under study so as to calculate the magnitude of the problem. There must be a denominator. The data provided by the Palestinian Health Ministry note that during the study period there was an average of 52,000 births in the West Bank. Thus, the proper perspective about the number of births at check points is that it yields on average 8.6 / year, which represents 0.016% of the births. As Shoaibi presents absolutely no data as to cause of deaths of the infants and/or the mothers (let alone their gestational age) it is impossible to interpret in anyway the relevance of any supposed delay at a checkpoint as a factor in their death.
This discussion about quality and reliability of a study which does not meet even the most basic standards of public health and epidemiologic research suggests a failure within the editorial process. It is compounded by the inappropriate pronouncement that these data are consistent with “crimes against humanity”. Judicial analysis is the purview and expertise of proper judicial fora. Such fora are designed to evaluate if data meet the standards of evidence and reliability. Proper advocacy and defense have to be provided. A medical Journal lacking this expertise cannot evaluate such serious issues. As ombudsman you must surely believe that it is totally inappropriate for a medical journal such as the Lancet to serve as a platform for such highly charged political conclusions. Surely to publish a “study” that does not meet even the most minimum scientific standards of a peer reviewed journal, written by an author who has neither medical nor public health expertise, only debases the Lancet standards and reputation as a premier medical journal.
The normal channel for communication with a journal is to write to the Editor. However, no less serious than the article is the accompanying on-line comment from the Editor (July 5th 2011). Not only has he failed to maintain minimum scientific standards for publications in Lancet, but also he has become a one man judicial analyst and political advocate. While one can and should applaud the Lancet as a journal committed to furthering and “supporting research in collaboration between in occupied Palestine and scientists worldwide” such activities do not legitimate publishing ex cathedra judicial and legal conclusions. The Editor, too, makes the same claim as Shoaibi, that Israeli policy is “consistent with the criteria for crimes against humanity”. Surely this conclusion is one for international judicial bodies, not for the editor of a scientific and medical journal. It amounts to unacceptable political advocacy.
I await your response as Lancet Ombudsman to these serious concerns, which are damaging to the reputation and standing of the Lancet in the international medical forum.
Arthur I Eidelman MD FAAP FABM
For identification purposes only:
Chair, Department of Pediatrics Shaare Zedek Medical Center (Emeritus)
Professor of Pediatrics, Faculty of Health Sciences Ben Gurion University of the Negev and Hebrew University – Hadassah School of Medicine
International Editor- Journal of Perinatology (Official publication of the Section of Perinatal Medicine of the American Academy of Pediatrics)
Department of Pediatrics
Shaare Zedek Medical Center
PO Box 3235
Jerusalem 91031 Israel