Category: medicine

The hypocrisy of the AMA (and other elite organizations like the NYT)

November 2, 2021 • 9:15 am

I call your attention to my post yesterday on the apparent metastasizng wokeness of the American Medical Association (AMA) in its new Medspeak guide, “Advancing Health Equity: A Guide To Language, Narrative and Concepts.” That guidebook, full of new medical euphemisms, was an almost unbelievable display of wokeness, so outré that it was funny—except of course that instantiated what’s happening in every college, every venue of mainstream media, and every professional and scientific organization in America. In fact, one of my friends who reads this site wrote me this assessment of the AMA pamphlet:

 I honestly think that the woke are minting new Republicans by the hour. We’ll be back to Trump, and then we can really kiss our collective ass goodbye.

Indeed. You don’t have to be a rocket scientist to see that!

But lest you think the whole AMA has gone woke, have a look at this article from The Hill (click on screenshot):

It’s pretty much what it says it is: the AMA President doesn’t want a “Medicare for all” system. Maybe for poor people (though they already have one), but President Dr. Patrice Harris says this:

The president of the American Medical Association (AMA) criticized “Medicare for All” as a “one-size-fits-all solution” on Wednesday, but acknowledged that some doctors, particularly younger ones, support the idea.

“We just don’t think a one-size-fits-all solution works,” Dr. Patrice Harris told The Hill when asked about a Medicare for All, single-payer system.

“And so, we believe that there should be choice for patient, choice for physician, and there should be a plurality of available options, but absolutely having a strong safety net,” she added in the interview at the group’s national advocacy conference in Washington.

Of course a “plurality of options” means different forms of medical insurance and that in turn means that doctors get to keep their high salaries and prestige. (I’m not of course implying that all doctors have this notion.)

Dr. Harris adds:

But attitudes among doctors could be changing. Asked if younger doctors are more open to single-payer, Harris said, “I’ve seen that, I’ve witnessed that.”

“I think there are folks of all, you know, age ranges and specialties that might support that,” she added. “But again, that’s the beauty of the AMA and our democratic process and our value of diverse thoughts and opinions.”

In other words, Harris’s sense of “diversity” is not the one we’re used to: she means, “Let a thousand insurance companies blossom,” which of course is good for the well-being of doctors, but not perhaps of patients who are well off or who have job-provided medical care. In fact, the article admits that:

The American College of Physicians, the second-largest doctors group after the AMA, made waves in January when it endorsed single-payer health insurance, as well as a public option, as ways to achieve universal coverage.

The rest of the health care industry, including hospitals, drug companies and insurance companies, remains strongly opposed to single-payer, though.

Many doctors worry that the payment rates under Medicare for All would be insufficient, given that Medicare currently pays lower rates than private insurance does.

This is about salary and prestige that some doctors are insistent on keeping. “But,” you might be asking yourself, “how can the AMA be against single-payer insurance and yet issue a document that is ultra-woke in prescribing the language to use?”

Well, how doctors use language to conform to current ideology doesn’t affect their wages, does it? Instead of coining euphemisms, if they really cared about the well being of poor people and minorities, they’d be lobbying Congress for “Medicare for All.”

The point, as Batya Ungar-Sargon suggests in her piece below on Bari Weiss’s site, is that Wokeness is not mainly a race issue but a class issue, one largely promulgated by privileged and well-off white people who use it to buttress their self-esteem while simultaneously propping up a meritocracy from which they benefit. That, after all, is what the AMA seems to be doing.

Click below to read Batya’s article. She’s an opinion editor at Newsweek and has a new book out, Bad News: How Woke Media Is Undermining Democracy. Read also Bari Weiss’s introduction to her article.

Now Ungar-Sargon is concerned with journalism and not medicine, but there are parallels. Journalism was once a middle-class profession, but has risen to an elite profession whose practitioners are not only uber-woke (at least in the Left media), but also pretty well off (she gives some salaries).  Not all of them are white, but you already know that wokeness is promulgated primarily by the white folk that own and manage the MSM. As Ungar-Sargon says, “Once working-class warriors, the little guys taking on America’s powerful elites, journalists today are an American elite, a caste that has abandoned its working class roots as part of its meritocratic climb. And a moral panic around race has allowed them to mask this abandonment under the guise of ‘social justice.’”

And here’s her argument. The more I think about it, the more I think it does explain how elite organizations such as the AMA and NYT can at the same time promulgate big-time wokeness and yet try hard to keep their position as members of the “elite.”

. . .Wokeness perpetuates the economic interests of affluent white liberals. I believe that many of them truly do wish to live in a more equitable society, but today’s liberal elites are also governed by a competing commitment: their belief in meritocracy, or the fiction that their status was earned by their intelligence and talents. Today’s meritocratic elites subscribe to the view that not only wealth but also political power should be the province of the highly educated. Still, liberals see themselves as compassionate and progressive. And perhaps unconsciously, they sought a way to reconcile the inequality that their meritocratic status produces with the compassionate emotions they feel toward the less fortunate. They needed a way to be perpetually on what they saw as the right side of history without having to disrupt what was right for them and their children.

A moral panic around race was the perfect solution: It took the guilt that they should have felt around their economic good fortune and political power— which they could have shared with the less fortunate had they cared to—and displaced it onto their whiteness, an immutable characteristic that they could do absolutely nothing to change.

This is how white liberals arrived at a situation where instead of agitating for a more equal society, they agitated for more diverse elites. Instead of asking why our elites have risen so far above the average American, they asked why the elites are so white. Instead of asking why working-class people of all races are so underrepresented in the halls of power, white liberals called the working class racist for voting for Trump. Instead of asking why New York City’s public school system is more segregated than Alabama’s, white liberals demanded diversity, equity, and inclusion training in their children’s exorbitantly priced prep schools.

In other words, wokeness provided the perfect ideology for affluent, liberal whites who didn’t truly want systemic change if it meant their children would have to sacrifice their own status, but who still wanted to feel like the heroes of a story about social justice, who still wanted to feel vastly superior to their conservative and even slightly less radical friends.

This clarifies a lot of things, including the fact that wokeness is highest at the most prestigious universities: places like Harvard, Princeton, and Yale. It explains why many of the white Woke are obsessed with trivialities like policing languages, art installations, and other behavior, and don’t really get out there in society and actually help poor people.  It’s why they can get away with dismissing the poor and working class as racists because so many of them vote for Trump.

I don’t think (nor does Batya) that this is the sole explanation for fulminating Wokeness. But I think she’s got a handle on one reason, and an important one.

 

Kamala Harris gets an improperly administered Covid booster

November 1, 2021 • 1:00 pm

Kamala Harris got her booster shot for the Moderna vaccine on Saturday. Although at age 57 she’s below the normal age limit for getting a booster (65+), she’s eligible since she’s considered “at risk” because her duties place her in contact with many people, including Uncle Joe.

Watch the short video below and see how she gets the shot: in particular, notice how the guy pinches her arm before sticking the needle into the raised-up skin. That’s WRONG!

 

Well, actually, it’s not wrong for her, but neither is it the right way to inject vaccine into a healthy person when the vaccine is, like the Covid jab, supposed to be injected intramuscularly.  Here’s part of an article from KOLD.com in Tucson, Arizona: Click on screenshot below to read the whole thing.

Here’s the salient bit:

We asked Tucson family physician Dr. Cadey Harrel to show us the proper way to administer a COVID-19 mRNA vaccine.

Harrel said instead of pinching the skin, she spreads the skin to create a flat surface when injecting an intramuscular vaccine.

Following our investigation, the KOLD Investigates Team received an email from Dr. Nimrod Rahamimov at the Galilee Medical Center in Nahariyya, Israel.

Rahamimov is the head of the Department of Orthopedics and Spine Surgery at the Galilee Medical Center.

Rahamimov said he noticed people’s arms being pinched as COVID-19 vaccines were administered. He searched the medical literature and scholarly articles for any information on concerns of improper COVID mRNA vaccine administration.

“There was absolutely nothing,” Rahamimov said.

So, he expanded his search, which can be read HERE.

“I was Googling to see if it was mentioned anywhere else and I fell on your story,” Rahamimov said.

Rahamimov said Harrel’s demonstration is correct, but he wanted to find out what would happen if the vaccine was administered into a pinched arm. His hypothesis was that skin bunching might prevent the needle from reaching the muscle, instead, injecting the vaccine into subcutaneous fat.

To put this theory to the test, Rahamimov recruited 60 volunteers, both males and females.

And the results of the test are below in a paper in Vaccine by Dr. Rahaminov and his colleagues (click on screenshot; access is free).

The upshot is that if you have too much fat on your arm, pinching may cause the needle to not penetrate the muscle below the fat sufficiently to give a good injection. 10% of the people in the trial were in danger of such an outcome, and Americans in general have a high incidence of obesity. Now Kamala isn’t fat—in fact, I think she’s athletic—but in either her case nor in the case of overweight people there should be NO PINCHING. As they say below in the paper “pinching is recommended only in patients with suspected lower muscle mass.”  That’s not Kamala, so the doctor that gave her the well-publicized injection set a bad example. To wit:

We have found that in 6/60 (10%) of our study population, skin bunching can create a skin-to-muscle distance of 20 mm or greater, leading to insufficient muscle penetration concerns. 5/6 (83.33%) of these subjects had a BMI greater than 30. Searching the PubMed and Google scholar databases, we have not found another study describing the differences in skin-to-muscle distance when bunching the skin over the injection site or if the needle is directed at a different angle than 900. Using real-time sonography we were able to visualize this substantial difference and quantify it.

Ten out of the sixty subjects (10–60, 16.6%) were obese, having a BMI of 30 or more. As having a skin-to-deltoid distance of 20 mm or more strongly correlated with obesity, and the obesity rate in the Israeli general population is 23.2% for men and 29% for women, our study under-represented this group, hence it is reasonable to assume that more than 10% of the general population will have an injection depth of 20 mm or more if their skin is bunched while receiving their vaccination. In countries where obesity is more prevalent – these differences may be even higher.

. . . Muscle bunching is indeed recommended only in patients with suspected lower muscle mass, but in common practice this recommendation is difficult to implement for two reasons: BMI is not always calculated, especially in mass-immunization efforts such as the current pandemic, and because muscle bunching requires anatomical understanding and some practice to do correctly. The two radiologists performing the measurements in our study found that even when done under US control, some practice and repeated attempts were needed to actually bunch the deltoid muscle. We feel that the vaccine provider in the field, sometimes a person with only basic training, will find this task beyond their skill set.

. . . Our study’s main significance is in the multipliers. Although the immune effects of inadequate IM penetration while receiving an mRNA vaccine have not been clinically studied, and the concern is valid in a relatively small number of patients, multiplying this small effect by the large numbers expected to receive mRNA vaccines raises concerns that many millions of people will be under-vaccinated globally, especially in countries where obesity is prevalent. In countries opting for a one-dose regimen, the effect might be more profound as there is no “second chance” if the first was indeed mis-administered.

The lesson for you: they should NOT pinch your skin up when they give you your jab unless for some reason they think you have poor muscle mass and are not obese.

I’m not a doctor—I just play one in college—but I thought this was fun to point out.

 

Jesse Singal: The AMA jumps the Woke Shark, introduces Medspeak

November 1, 2021 • 9:15 am

The American Medical Association (AMA) and the American Psychological Association are now beyond redemption since they’ve decided to steep their organizations in “progressive” ideology and also to issue fulsome apologies for their past behavior. But this I found unbelievable:  tweets sent by Jesse Singal and forwarded by Luana. The AMA is policing language to conform to an extreme Leftist view of the world.  Welcome to Nineteen Eighty-Four‘s Medspeak:

I’ll just expand the text:

What the AMA is doing here is taking statements of fact and then politicizing them by ascribing those facts to various debatable ideological positions. In other words, they’re adding irrelevant ideological material in service of their viewpoint. This of course stifles any discussion. But since when is the AMA supposed to police language?

I’ll add a few more of Singal’s tweets from that thread; you can enlarge the text for yourself.  There are 15 tweets in the thread.

You can check Singal’s excerpts out by clicking below, which will take you to the 54-page document. It provides hours of amusement unless you have high blood pressure, in which case you’ll blow an artery.

They also have a convenient glossary where you can amuse yourself by turning up stuff like this. Note the “subjective” part, designed to denigrate an objective sexual binary (yes, of course there are very rare exceptions, like hermaphrodites, but they are not members of “a different sex”). The glossary doesn’t even give a hint that there is “biological” sex defined by relative gamete size, and virtually all humans can be classified as one or the other of two sexes. When I sorted flies, they were either male or female (with dissection invariably showing the correct gametes) or, once every six months or so, a gynandromorph, reflecting loss of a chromosome.


Throughout there is unquestioning endorsement of the ideas of Ibram Kendi and Robin DiAngelo:

Why is that in there? Why would a doctor ever need the concept of “white fragility”? It’s in there to cater to the Woke.

More: an unquestioning acceptance of the tenets of Kendi, with no dissent permitted.

Enough for me. It appears we’ve lost this battle, but I still find value in pushing back, which may inspire others to follow.

[Added note by GCM: The AMA brochure is even nuttier than it appears on first view. It says not to use the words vulnerable, marginalized, and high-risk, but then uses the words repeatedly in its preferred usages!! It’s as though the approved and disapproved sections were written by two different people!]

My stitches are out!

October 22, 2021 • 10:15 am

I had no idea that stitch removal was absolutely painless. I thought they’d have to slide the stitches back through the wound, which might hurt, but no: they just cut the stitch knots and use tweezers to pull out the threads.  So it took only a short while to remove my 18 stitches this morning.

(Earlier posts detail my accident and then the initial stitching.)

Here’s the before this morning, after the dressings were removed. I had two gashes, you might recall, and you’ll see, compared to the earlier shots, they’ve healed up nicely in nine days.

After stitch removal, they lightly covered the gashes with 3M “Steri-Strips,” which I’m to wear until they fall off (a few days). Until then, I still have to shower with a plastic bag over my hand and then apply Neosporin.

I have to say that the two women who took care of me, the physician’s assistant who so carefully stitched me up (she said that good stitching is a work of art) and the nurse-practitioner who removed the stitches, were both very careful and also informative and personable. I had good treatment at the U of C emergency room, even though there was a wait. (Some people have to wait up to 15 hours in the ER, I’m told! I got treated after two hours because I was bleeding like a stuck pig.) Kudos to the stitcher, initials AT, and if she sees this I’d like to thank her by email and show her the outcome.

My hand is healing (I hope)

October 18, 2021 • 12:30 pm

TRIGGER WARNING!

I thought you might like to see how my hand is healing after the mishap I had last Wednesday (there are comparison pictures of my hand at this link and pictures of the scene here). In short, when I was trying to break a fall, my hand went through a pane of glass on my office bookcase, causing two deep lacerations that required 18 stitches in toto.

Every day the lacerations are dressed, which involves putting Neosporin on the gashes and then taping a gauze pad over them. I keep my hand dry and when I shower I put it in two plastic bags secured with two rubber bands around my wrist.  Try washing your hair that way, or washing your right armpit when your left hand is encased in plastic bags!

Anyway, it appears to be healing okay, with no signs of infection except a slight redness, and, fortunately, the flap of skin in the first photo did not die (the nurse practitioner told me that was a possibility).

I get the stitches removed Friday morning.

x

Is now the winter of our discontent?

July 31, 2021 • 12:15 pm

I was talking to a friend last night who told me how worn out she was from the pandemic—and she has family all around her, including two grandkids. That made me realize how worn out we all our from our more-than-a-year sequestration. Nobody has been immune.

And now the specter looms of yet another lockdown and mask festival, this time caused by the delta variant of Covid, which can not only infect those who are doubly vaccinated, but can live in huge numbers in their nasal passages and infect other vaccinated people.  A huge number of Americans are resisting not only getting vaccinated, but also to wearing masks. Some yahoo governmental officials have declared that they won’t even consider mask mandates. All of this this presages another tough time this fall and winter. These are my predictions, and I dearly hope I’m wrong.

a.) There will be another surge in infections, which in fact is starting now, and breakthrough infections will start happening with the vaccinated. Other variants may arise even more dangerous than the delta. Kids will start getting the virus.

b.)  Booster shots will be instituted by the fall, and the smart folks will get them. In fact, I think we’ll need at least an annual COVID shot because immunity is wearing off faster than many thought.

c.) Perhaps more Americans will start wising up about vaccination and masking, but not enough of them. On Thursday heard four healthcare workers on the NBC Evening News explain why they didn’t want to get vaccinated. Healthcare workers! One said she didn’t trust the CDC. Another, confronted with the “facts” about vaccine efficacy, said she didn’t believe them.

d.) We will start having more lockdowns and mask mandates, and people, worn out from the last ones, will be even more resistant than before. Eight of the fifty states have indoor mask mandates. As of now, only two of of them (Nevada and Hawaii), as well as Washington, D.C., include the vaccinated. But of course we know now that the vaccinated can not only get infected, but spread the virus. (The just don’t get as sick as the unvaccinated.)

d.) As schools start to open, and the concert/entertainment festivals start, superpreader events will occur.  (The giant Lollapalooza Music Festival is going on right now in Chicago. You can get in if you wear a mask, but if you’re unmasked, you’re required to show a negative Covid test in the last three days or your vaccination card. But which masked people will  be keeping them on in the huge crowd?)  This all will lead to more lockdowns and other restrictions.

e.) Schools will open soon. Many kids have not been vaccinated, and nobody under 12 is even eligible. What with the Delta variant about, which makes younger people sicker than the previous variants, proper social distancing, air filtering, and mask wearing are essential for live classes. Everybody connected with school is sick of virtual teaching, so schools will desperately try to stay open “live”. This will cause problems, and many schools may go back to virtual classes.

The upshot: the “Summer of freedom” we all expected is dissolving fast, and I suspect we’re facing another wearing Fall and Winter of Restrictions. Many more people in the U.S. will die than would have had they gotten their jabs, and we’re all in for more restrictions, masking, and travel bans.

In short, it’s going to be tough until well into 2022. Such is my prediction, which is mine. It’s depressing. And you don’t have to be a rocket scientist to see it coming.

 

The Delta variant of COVID-19 (caption from NPR), which is more dangerous because it proliferates faster in the respiratory tract and reaches higher numbers: 1,000 times higher than previous variants.

The numerals in this illustration show the main mutation sites of the delta variant of the coronavirus, which is likely the most contagious version. Here, the virus’s spike protein (red) binds to a receptor on a human cell (blue). Juan Gaertner/Science Source

Israel can’t catch a break: The rejected vaccine exchange with Palestine

July 16, 2021 • 12:00 pm

There is nothing that Israel can do, however praiseworthy, that isn’t criticized by the Israel- and Jew-haters of the world. What about the free and open gay community in Israel, while at the same time being gay is a criminal offense in Palestine? Well, that’s just “pinkwashing”, something Israel’s accused of doing just to gain the approbation of the world, not because they believe in equal rights for gays.

The latest example of a good deed that Israel tried to do, but was rejected by Palestine, is recounted in the Tablet article below (click on the screenshot). It involves a vaccine exchange with Palestine, which the Palestinians rejected for no good reason. (It reminds me of their repeated rejection of peace overtures.)

This one’s easy to recount. First realize that, according to the Oslo Accords, Israel is not responsible for health care in the Palestinian Territories, including vaccines. Although a lot of people damned Israel for not providing COVID vaccines for Palestine, they didn’t realize that they weren’t supposed to. Palestine is, according to Oslo, responsible for its own healthcare. Nevertheless, when Netanyahu was Prime Minister, vaccine was secretly given to Palestinians, probably the bigwigs in the government.

Now, however, the new Israeli government announced a deal to transfer 1.2 million doses of Pfizer vaccine to Palestine. The vaccines were going to expire at the end of May, the end of June, and the end of August, but were going to be given to Palestine in three batches in return for the Palestinians returning equal amounts of their own Pfizer allotments to Israel in October.  Here’s the announcement from the Israeli Minister of Foreign Affairs.

Palestine agreed to this at first. After all, it’s a win-win situation: Israel has most of its population vaccinated, the vaccines could be used immediately by Palestine while they were still good, and Palestine could replenish the Israeli supply later. Palestine has a low vaccination rate and a high infection rate. They need the vaccine now, not in October.

I suspect this is part of the new Israeli government’s desire to take a softer stance towards Palestine. But, as you might expect, it didn’t work.

After negotiating the deal, Palestine rejected it, and for no good reason. As Tablet explains:

But the deal was short-lived. Mere hours after it was announced, the Palestinian Authority abruptly canceled the entire arrangement. The official reason was that the initial batch of 100,000 vaccines were too close to their expiration dates. The real reason was that they had received extremist backlash on social media over working with Israel.

The conspiratorial notion that Israel deliberately sent unusable vaccines to the Palestinians would later be exposed by events, after both Israelis and South Koreans happily made use of the doses. But it was obviously a lie at the time. The vaccine swap had been in the works for months, and every detail had been carefully vetted by the Palestinian Authority, including the expiration dates. As noted, the entire purpose of the arrangement was to swap soon-to-expire doses for distant doses, so that each population would have vaccines when they most needed them. Naturally, Israel first sent over the doses that expired that month, so that they could be immediately administered. This wasn’t a bait-and-switch, it was the plan. It was a feature—spelled out in the official Israeli statement announcing the deal—not a bug.

The fact that the vaccines were indeed usable comes from the observation that the first rejected batch was used to inoculate Israeli teenagers, while the second batch of 700,000 doses has been traded to South Korea, who is using them now (they also have a high infection rate), and will return the doses when they get their own later. The vaccines were not past their expiration date; they just needed to be used now.

There’s more:

But this arrangement was not explained to the Palestinian population, which allowed extremist and anti-vax elements to turn the public against the supposedly subpar “Israeli vaccines”—a campaign which was no doubt helped by preexisting levels of vaccine hesitancy among Palestinians. Local social media began overflowing with protests against the agreement, and rather than explain how it worked, the Palestinian leadership folded immediately. Of course, had the real issue been the expiration dates of the first batch of vaccines, the obvious solution would have been to renegotiate the deal to exclude them. But that was not the real issue, and so the entire deal was called off.

This reminds me of Abba Eban’s famous quote after the Palestinians had rejected one of the many peace deals they were offered: the Palestinians “never miss an opportunity to miss an opportunity.”

And it’s not just Palestine that’s trying to shift the blame to Israel for this debacle: the Western media and NGOs are helping as well:

But that political failure is unlikely to be rectified anytime soon due to the failures of two other entities that might have pressured the Palestinian Authority to change course: the media and the human rights community.

In June, rather than rebuke the Palestinian Authority for caving to extremists, several prominent NGOs ranging from Human Rights Watch to Physicians for Human Rights went to bat for the vaccine rejection, credulously echoing the false claim that the doses were essentially expired and unusable. These organizations had the contacts and the expertise to understand that this was not the case, but chose not to employ them, instead reflexively putting forward partisan talking points. Had they instead called out the Palestinian Authority for placing politics ahead of public health, its leaders might have altered course.

Here’s a tweet from the director of Human Rights Watch, which hates Israel, blaming that country for the failure:

That’s simply a lie!

Tablet says more:

Meanwhile, the international media did not do much better. Of all people, journalists should reasonably be expected to get to the bottom of whether Israel or the Palestinian Authority was telling the truth about the vaccines. But instead, too many outlets covered the entire affair in “he-said, she-said” terms, as though the truth was unknowable, rather than something that could be determined by careful reporting. The closing of the New York Times dispatch was emblematic of this approach:

Those who accepted Israel’s official position about the donations said the authority’s refusal to accept the vaccines had dented claims that Israel was to blame for the slow vaccination rate among Palestinians. But those who believed the Palestinian position said Israel had acted in bad faith by making the authority an offer that it had no choice but to refuse.

Had the Palestinian Authority originally agreed to accept the vaccines with these expiration dates? Could the doses be administered in time? Or was Israel’s leftist health minister, whose party includes an Arab minister, involved in a sinister scheme to foist unviable vaccines on the Palestinian population? If only there were some journalists around to find out.

There are those, like Human Rights Watch, that hate Israel so much (I wonder why?) that they simply can’t admit that on this one the Palestinians screwed up. Israel tried to do something good for both Palestine and Israel, and would surely save a number of Palestinian lives. When Palestine realized that it would make Israel look good and anger the anti-Israeli-anti-vaxers, they rejected the deal.  Consider that. Both the NGOs and the Palestinians would rather see their people die of COVID than accept the offer from Israel. So now the South Koreans are saved at the expense of Palestinians. (The fate of vaccines expiring in August is not yet known.)

With an attitude like that, it seems useless for Israel to reach out to Palestine to soften the enmity. It now seems as if the Palestinians won’t rest until they occupy Israel and that country disappears. The two-state solution appears to be dead, and is clearly opposed as well by many on the American Left (e.g., the Squad in Congress).

If you’d rather see your own people dead than negotiate a win-win deal with Israel, you are a dysfunctional territory. But we already knew that, for Palestine already uses its civilians as cannon fodder to protect Hamas and its rocket sites from Israeli attacks.