How Israel’s occupation devastated Gaza’s health system

Even before the present Israeli incursion into Gaza, the health system in the occupied territory was in precarious shape. A fourteen year long blockade on Gaza via land, air and sea meant that its health system has frequently been described as “on the brink of collapse”.

As Israel’s attack on Gaza continues, the destruction leveled at Gaza’s health system and infrastructure only keeps escalating.

This week, Gaza’s only coronavirus laboratory and the Palestinian Ministry of Health offices were bombed. To date, six hospitals and eight primary care facilities as well as roads leading to Gaza’s main Shifa hospital have been damaged.

Global health parlance draws on the concept of ‘Health System Resilience’ when talking about the capacity for a health system to ‘bounce back’ after a catastrophe.

Conceptually, ‘resilience’ centres responsibility for positive change on the agent. It appears that local health agents have been stretching their limited resources for the longest time. When it comes to Gaza we need to recognise agency but centre context.

This context is the occupation.

A slow asphyxiation

The blockade placed by Israel on Gaza in 2007, which came into effect after Hamas won the Palestinian parliamentary elections the year before, has placed tremendous strain on every level of Gaza’s health system.

Most downstream negative health outcomes trace their origins to the occupation and blockade.

With its borders effectively being controlled by Israel, the free movement of people and goods in and out of the area is restricted. The building blocks of health - its social determinants -  like access to clean water, a regular electricity supply and effective sanitation systems, are insecure as a result. 

Meanwhile, life expectancy in Gaza and the West Bank was found to be “more than 8.5 years less than life expectancy in Israel.”

The occupation and blockade have had direct effects on components of healthcare. The restricted movement of goods as well as dual-use restrictions affect the medical equipment maintenance supply chain. A customs union with Israel means that the Palestinian Authority (PA) was found to pay on average 6.9 times more for generic medications compared to international norms.

The restricted movement of people means that seeking medical care outside the territory requires Israeli-granted permits. In 2018 for example, two-fifths of exit permit applications were denied, impacting the survival rates of cancer patients.

The restricted flows of healthcare personnel as well as the loss of qualified and experienced healthcare professionals through Israeli attacks on Gaza, contribute to the number of health professionals per 1000 (of the population) falling beneath the WHO-recommended threshold for doctors, nurses and midwives.

A UN Commission of Inquiry into the 2018 protests in Gaza “found reasonable grounds to believe that Israeli snipers intentionally shot health workers, despite seeing that they were clearly marked as such”.

The most recent attacks on Gaza have resulted in the killing of Dr Ayman Abu al Ouf, head of internal medicine at Al Shifa hospital, who, in a tragic twist, was also head of the Shifa hospital’s coronavirus response unit. In the same attack, Dr Mooein Ahmad al Aloul, a psychiatric neurologist, was also killed.

In an area where resources are difficult to come by, the loss of these doctors, holding scarce and necessary skills, is sure to be acutely felt.

Vaccine apartheid

The challenge of managing Covid-19 in densely populated areas under normal circumstances is understandable. When this is compounded by a fragile and fragmented health system, it does not come as a surprise that the Palestinian Ministry of Health declared almost all of Gaza a “red zone” earlier this month, indicating high community transmission rates.

Israel has been internationally lauded for its efficient vaccination campaign which extends only to Israeli citizens, Palestinians working in Israel and the illegal Jewish settlements in the West Bank. Citing the Oslo Accords, Israeli authorities deny their responsibility to provide vaccine coverage to Palestinians in the West Bank and Gaza, saying that this responsibility lies with the PA.

While the PA is sourcing a nominal amount of vaccines from COVAX, Russia and the UAE, Israel has donated only 5,000 Moderna doses and 200 Pfizer doses for Palestinian medial workers, despite Israeli epidemiologists saying that the region is “one epidemiological unit” .

While Israel is sidestepping the responsibility for the health of the Palestinians under its occupation, a look at the health system in Gaza reveals an area that is technically administered by the PA but realistically controlled by Israel. 

Under the Fourth Geneva Convention, Israel is “to maintain health services in the occupied territory” including “prophylactic and preventative measures necessary to combat the spread of contagious disease and epidemics”.

One of the most tragic consequences of the protracted blockade and the military incursions into Gaza has also been the impact on the mental health of the population. 

Suicide and suicidal ideation is becoming a growing public health concern with people experiencing hopelessness around employment, finances and future plans. Children in Gaza are affected by PTSD, anxiety and depression.

The time for appeals to Israel and international security bodies from a humanitarian perspective has passed. The global health community from academics to practitioners as well as those supporting health as a basic human need, must align and coordinate efforts to isolate and hold Israel and countries supporting it militarily, diplomatically and financially to account.