Anti-Palestinian Racism Survey: Patient Exposure Associated with Health Harm in U.S. Healthcare Settings

Overview:

This report summarizes additional findings from a US-based national survey^[1] investigating anti-Palestinian racism. The survey was conducted from March 1st through April 3rd, 2024 with approval from the University of California, San Francisco Institutional Review Board (IRB). The current analysis focuses on anti-Palestinian racism in the healthcare setting.

“Anti-Palestinian racism is a form of racism that “silences, excludes, erases, stereotypes, defames, or dehumanizes Palestinians or their narratives” and may be experienced by Palestinians and those perceived to be Palestinian as well as non-Palestinians who support Palestinian human or civil rights.^[2]

This survey was designed in consultation with the Arab Canadian Lawyers Association and based on the description of anti-Palestinian racism delineated in their seminal report: “Anti-Palestinian Racism: Naming, Framing and Manifestations.”^[3]

A 5-minute, voluntary national survey was developed based on information from the “Anti-Palestinian Racism: Naming, Framing and Manifestations” report, consultation with the Arab Canadian Lawyers Association, and consultation with pediatricians and other physicians, anti-racist and communication experts, educators, students, and community members. The survey was approved by the UCSF IRB prior to implementation. This survey utilized a voluntary convenience sample and was conducted online, distributed via email to multiple social media lists, physician groups, and other online lists. The results should not be interpreted as nationally representative.

The survey was developed to assess the impact of anti-Palestinian racism on both Palestinians and non-Palestinians. Findings reflect respondents’ self-reported experiences and should be interpreted accordingly.

Through our work as researchers, physicians, educators, and psychologists, we realized that anti-Palestinian racism affects both Palestinians and non-Palestinians. However, since anti-Palestinian racism is under-recognized and under-studied, many people are unaware of what they are experiencing. We hypothesized that anti-Palestinian racism impacts a larger and more diverse population than was previously understood, with potentially significant negative health impact. To our knowledge, this is the first national study designed to investigate this hypothesis.

Review of Initial Findings:  April 2024 Anti-Palestinian Racism Survey Preliminary Findings Report:

 Over 1200 respondents completed the survey. The majority of respondents identified as non-Palestinian (72.5%). The survey sample was racially and ethnically diverse, with self-reported race/ethnicity as follows: 35.8% Arab or Arab American, 32.0% White or European American, 22.7% Asian or Asian American, 7.3% Hispanic or Latinx, 6.9% multiracial or multiethnic, 3.7% Indigenous (including Indigenous American, Australasian, Alaskan, Arctic Indigenous, Native Hawaiian, Pacific Islander, and other Indigenous), and 3.6% Black or African American. Most respondents identified as women (61.0%) and non-Muslim (57.9%) including, but not limited to, Christian, Jewish, Buddhist and no religion. The sample was comprised of a diverse age range: 18–24 years (9.4%), 25–34 (28.6%), 35–44 (29.6%), 45–54 (17.8%), 55–64 (8.0%), 65–74 (5.2%), and 75+ (1.5%). In addition, 31.7% of respondents identified as LGBTQ+.

Summary of initial findings:

• 64.6% of respondents experienced anti-Palestinian racism either directly or online;
• 63.4% of respondents reported experiencing silencing, exclusion, harassment, physical threat or harm, or defamation while advocating for Gaza and/or Palestinian human rights;
• 73.5% of respondents felt alone or isolated in their concern about Palestinian human rights;
• 87.9% of respondents had witnessed others experiencing anti-Palestinian racism either directly or online;
• 55.3% of respondents were afraid to speak out about what is happening to Palestinians in Gaza or for Palestinian human rights in general.

Full initial findings report can be viewed here.

Anti-Palestinian Racism Survey: Patient Exposure Associated with Health Harm in U.S. Healthcare Settings

This report is focused on the results from our survey regarding respondent exposure in U.S. healthcare setting.

Exposure was defined as experiencing and/or witnessing anti-Palestinian racism.

Patient exposure was defined as:

1. 1. Experiencing or witnessing anti-Palestinian racism as a patient in a healthcare setting from doctors, nurses or staff.

Healthcare provider exposure was defined as either:

1. 1. Experiencing or witnessing anti-Palestinian racism as a healthcare provider in a healthcare setting from patients and their families or;
   2. Experiencing or witnessing anti-Palestinian racism as a healthcare provider in a healthcare setting from other healthcare staff.

A total of 1005 respondents reported exposure to anti-Palestinian racism. Of these, 216 (21.5%) reported exposure in the healthcare setting: 84 respondents (39%) reported exposure as a healthcare provider only (Provider Only),  74 (34%) as a healthcare provider and as a patient (Both Patient And Provider), and 58 (27%) reported exposure as a patient (Patient Only).

Demographic Patterns

Adults aged 25-44, women, non-binary respondents, Muslims, Christians and those with no reported faith had the highest proportions of reported exposure in the healthcare setting (>= 20% for each category). Of respondents exposed to anti-Palestinian racism in the healthcare setting, 69% did not identify as Palestinian or Palestinian-American while 31% identified as Palestinian or Palestinian-American.

Impact on Health

We examined the impact of exposure to anti-Palestinian racism on respondents’ physical and mental health. Severe health impact was defined as reports of respondents feeling their mental or physical health has been harmed (by personally experiencing or witnessing anti-Palestinian racism) most or all of the time. Options ranged from “I have not felt this at any time to I have felt or I feel this most or all of the time.”

Respondents were provided with examples of mental and physical health impacts. Mental health effects included anxiety, depression, difficulty concentrating, alienation, hyper-vigilance, and/or insomnia. Physical health effects included fatigue, headaches, loss of appetite, and/or body pain.

Exposed vs. Not Exposed to Anti-Palestinian Racism in Healthcare Settings

Severe health impact was reported by 60% of respondents exposed in the healthcare setting compared to 38% of respondents who were not exposed in the health care setting (p < 0.001). (Figure 1) When controlling for confounding variables (age, gender, faith, race, Palestinian identity and geographic region), respondents exposed in the healthcare setting had twice the odds of reporting severe health impact than those not exposed in the health care setting. (Figure 2)

Isolation and Fear

The vast majority of respondents exposed to anti-Palestinian racism in a healthcare setting (91%) reported feeling isolated or alone in their concern for Palestinian human rights compared to 77% without exposure in healthcare settings (p < 0.001). (Figure 3) In addition, 73% of exposed respondents reported being afraid to speak out about what is happening to Palestinians in Gaza or for Palestinian human rights compared to 57% without exposure in healthcare settings (p < 0.001). (Figure 4)

Social Harm

Social harm was defined as experiencing silencing, exclusion, harassment, physical threat or harm, or defamation while advocating for Gaza and/or Palestinian human rights. Of all respondents exposed to anti-Palestinian racism, 81% of those exposed in the healthcare setting reported social harm, compared to 66% of those not exposed in a healthcare setting (p < 0.001). (Figure 5)

Impact of Exposure to Anti-Palestinian Racism in U.S. Healthcare Settings: Focus on Patient and Provider Experiences

Of the 216 respondents who experienced anti-Palestinian racism in the healthcare setting, 84 (39%) reported exposure as Both Patient And Provider, 74 (34%) reported exposure as a Provider Only, and 58 (27%) reported exposure as a Patient Only.

Of respondents exposed in a healthcare setting, 76% of Patient Only reported severe health impact compared to 54% of all providers (Provider Only and Both Patient And Provider). (Figure 6) There was no statistically significant difference in severe health impact when comparing Provider Only to Both Patient And Provider.

The vast majority of respondents (91%) exposed in the healthcare setting reported feelings of isolation regardless of whether they were exposed as patients, providers or both. In addition, over 70% of exposed respondents reported feeling afraid and 90% of Patient Only respondents and 78% of all providers (Provider Only and Both Patient And Provider) exposed in a healthcare setting reported social harm. (Figure 7)

Outcomes by Exposed Type

Importantly, Patient Only respondents had nearly three times the odds of reporting severe health impact than those with any exposure as providers (Provider Only and Both Patient And Provider), when controlling for age, gender, faith, race, Palestinian identity, and geographical region (adjusted odds ratio  2.81 (95% confidence intervals 1.29, 6.46)). (Figure 8)

Summary

Our findings show statistically significant associations between exposure to anti-Palestinian racism in healthcare settings and reported harms, including mental and physical health harms, among patients and providers across diverse demographic groups.

Patient Only respondents were particularly vulnerable to negative health impact, with a nearly threefold increase in the odds of severe harm to physical and/or mental health compared to those exposed as providers (Provider Only and Both Patient And Provider).

Importantly, respondents exposed to anti-Palestinian racism in the healthcare setting had twice the odds of reporting severe mental and/or physical harm, compared to those who were not exposed in the healthcare setting. In addition, respondents exposed to anti-Palestinian racism in the healthcare setting, reported statistically significant increases in isolation, fear and social harm compared to respondents not exposed in healthcare settings.

This survey utilized a voluntary online participation methodology and is not a representative national sample. Findings reflect respondents’ self-reported experiences and should be interpreted accordingly. We cannot make any inferences to a representative national population at this time. Nonetheless, the statistically significant associations observed warrant careful institutional review and merit further study.

In addition, the Joint Commission has clarified that racism and discrimination undermine patient safety. When anti-Palestinian racism produces harm or increases risk to patients, including delays in care, communication breakdowns, compromised informed consent, inequitable pain management, unsafe discharge, care avoidance, or patient-reported mental and physical health effects, including fear and isolation that obstruct safe communication and help-seeking, it creates conditions that increase risk of harm. Addressing these risks falls squarely within institutional quality and patient safety obligations.

Our analyses are consistent with extensive peer-reviewed literature documenting that exposure to discrimination and racism in healthcare settings results in heightened negative health outcomes.^[4][5][6][7] Our findings raise serious patient safety concerns that warrant immediate institutional attention and intervention to assure the wellbeing and safety of our patients.

Recommendations

1. 1. Hospitals, medical organizations and healthcare institutions must prevent, detect, and respond to anti-Palestinian racism as a patient-safety issue.
   2. Healthcare institutions should ensure consistent treatment of patients from diverse backgrounds, including Palestinians and non-Palestinian allies in compliance with their civil rights obligations.
   3. To effectively counter the negative health impacts of exposure to anti-Palestinian racism in healthcare settings, institutions should include anti-Palestinian racism in implementation of Joint Commission requirements on health equity.
   4. Public and state-affiliated healthcare institutions must enforce constitutional protections including the First Amendment, and all healthcare institutions must comply with applicable civil rights protections including Title VI and Title VII protections for both Palestinians and non-Palestinians impacted by anti-Palestinian racism.
   5. Institutions should fund research, education and training on anti-Palestinian racism.
   6. A checklist of interventions aligned with Joint Commission recommendations can be found in Appendix I of this report.
2.  

Appendix I

Institutional Recommendations to Prevent and Address Anti-Palestinian Racism in Healthcare

The following recommendations are grounded in established patient safety, health equity, accreditation, and civil-rights standards. They align with the Joint Commission’s National Patient Safety Goal to Improve Health Care Equity (NPSG.16.01.01) by integrating leadership accountability, assessment of barriers to care, disparity analysis, structured action planning, corrective intervention, and transparent stakeholder reporting. These recommendations apply existing quality and safety processes, including safety event review, Sentinel Event principles, trauma-informed care, and non-retaliation protections, to address documented harms associated with anti-Palestinian racism in healthcare settings as described in Anti-Palestinian Racism Survey: Patient Exposure Associated with Health Harm in US Healthcare Settings. In doing so, they operationalize current institutional responsibilities to ensure safe, equitable care for Palestinian patients, individuals perceived to be Palestinian, and non-Palestinian allies impacted by anti-Palestinian racism.

1. Identify an Individual to Lead Activities to Improve Health Outcomes for All Patient Groups

The organization will:

• Designate an executive-level leader accountable for implementing health equity requirements under NPSG.16.01.01 and for preventing, detecting, and responding to anti-Palestinian racism as a patient safety and quality issue.^[8]
• Require governing board oversight of anti-Palestinian racism metrics, including incident trends, response timelines, corrective actions, and disparities in outcomes.^[9]
• Integrate anti-Palestinian racism indicators into quality, safety, and equity dashboards.^[10]
• Communicate institution-wide that racism—including anti-Palestinian racism—is a patient safety issue.^[11]

2. Assess the Patient’s Health-Related Social Needs

The organization will:

• Assess health-related social needs (HRSNs) as required under NPSG.16.01.01 and include barriers created by anti-Palestinian racism, including fear of reporting, intimidation, exclusion, or harassment that interferes with safe care.^[12]
• Provide meaningful access for individuals with limited English proficiency, including qualified interpreter services and translated materials at no cost, consistent with Section 1557 language-access requirements.^[13]
• Maintain confidential, multilingual reporting pathways (in person, phone, and digital) for patients and staff to report anti-Palestinian racism during active care.^[14]
• Standardize high-risk clinical touchpoints (registration, triage, consults, discharge) to ensure respectful communication and explicit prohibition of anti-Palestinian racism and harassment.^[15]

3. Analyze Quality and Safety Data to Identify Differences in Health Outcomes

The organization will:

• Integrate anti-Palestinian racism metrics into annual safety and equity dashboards.
• Analyze quality and safety data to identify differences in outcomes across patient groups including Palestinians and their allies, consistent with NPSG.16.01.01.^[16]
• Stratify data by relevant sociodemographic characteristics (e.g., race, ethnicity, national origin, language) to detect disparities affecting Palestinian patients, those perceived to be Palestinian and non-Palestinian allies.^[17]
• Track and trend reports of anti-Palestinian racism within the patient safety reporting system.
• Review anti-Palestinian racism related incidents quarterly to determine whether they produced harm or increased risk to patients, including delays in care, communication breakdowns, compromised informed consent, inequitable pain
• management, unsafe discharge, care avoidance, or patient-reported mental and physical health effects, including fear and isolation that obstruct safe communication and help-seeking.^[18]
• Conduct recurring confidential surveys including anti-Palestinian racism specific exposure indicators (e.g., silencing, erasure, stereotyping, dehumanization, defamation) and associated health impact measures.^[1]
• Track and review anti-Palestinian racism incidents with the same rigor as other safety events.

4. Develop an Action Plan to Improve Health Outcomes

The organization will adopt and implement a written action plan that includes:

• A board-approved nondiscrimination policy explicitly prohibiting anti-Palestinian racism, including silencing, stereotyping, erasure, dehumanization, defamation, harassment, and differential treatment tied to Palestinian identity or Palestinian human or civil rights advocacy.^[19]
• Defined investigative procedures with clear timelines for response and resolution.^[20]
• Real-time escalation protocols when anti-Palestinian racism is reported during active care.^[21]
• Standardize high-risk touchpoints (triage, registration, discharge, specialty consults) with concise scripts and equity checks.
• Corrective action mechanisms, including supervision, workflow revision, and discipline when violations occur.^[22]
• Mandatory workforce training addressing recognition of anti-Palestinian racism, trauma-informed response principles, and bystander intervention.^[23][24]

5. Take Action When the Organization Does Not Meet the Goals in Its Action Plan

When anti-Palestinian racism affects care delivery or results in harm, the organization will:

• Classify such incidents as patient safety events requiring formal review and corrective action.^[25]
• Conduct systematic investigation and root cause analysis consistent with Joint Commission Sentinel Event policy principles when severe harm or significant risk occurs.^[26]
• Prohibit retaliation against staff or patients who report anti-Palestinian racism, consistent with federal anti-retaliation protections.^[27]
• Provide trauma-informed support services for patients and staff impacted by anti-Palestinian racism.^[28]
• Address hostile workplace climates and clinician burnout as systemic threats to patient safety and equity using systems-based approaches.^[29]
• The organization will enforce Title VI of the Civil Rights Act, Section 1557 of the Affordable Care Act, and Title VII of the Civil Rights Act; prohibit retaliation for
  protected activity; investigate complaints without bias; protect against discrimination by association related to Palestinian identity, perceived Palestinian identity, or advocacy for Palestinian human or civil rights; maintain equal-treatment protocols for patients and staff of all backgrounds, including Palestinians and non-Palestinian allies; and, in public and state-affiliated institutions, uphold First Amendment^[30] protections for speech on matters of public concern (Pickering v. Board of Education)^[31] and associational freedom (NAACP v. Alabama)^[32], narrowly construe the official-duties limitation under Garcetti v. Ceballos^[33] to avoid chilling protected advocacy, and publish clear due-process investigation standards.^[34][35][36]

6. Inform Key Stakeholders About Progress to Improve Health Outcomes for All

The organization will:

• Publish quarterly, aggregate (non-identifying) updates on anti-Palestinian racism incident trends, response timelines, corrective actions, and outcome disparities.^[37]
• Maintain a standing advisory structure that includes Palestinian community members to review progress and recommend improvements.^[38]
• Communicate clearly to patients that care must be free of anti-Palestinian racism and provide accessible instructions for reporting and resolution.^[39]

About The Institute for the Understanding of Anti-Palestinian Racism (IUAPR)

IUAPR is a U.S.-based 501(c)(3) tax-exempt non-profit organization. Our interdisciplinary team is committed to empirically researching, educating and advocating on the impact of anti-Palestinian racism on individuals and communities across all sectors of society. IUAPR’s mission is to end racism against Palestinians and their allies including advocates for Palestinian rights and freedom.

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