Qazi Sarem Shabab
The land of Palestine has long been subject to conflict between the Palestinian Arabs and Israeli Jews. This conflict, which began before the mid-twentieth century, has displaced millions, many of whom continue to live as refugees. Frequent conflict escalation leads to considerable morbidity, mortality and, increasingly, strain on the Gazan health system.
This paper aims to critically evaluate the current health crisis in Gaza, both in terms of loss of life and damage to infrastructure. The impact of the conflict on the Gazan health system and the role of the international community in supporting and promoting health justice on the Gaza strip are also explored.
Overview of the health system in Gaza
The Gazan health system is vulnerable to conflict by virtue of the complexities introduced by a combination of public, military, non-government and private health agencies. The healthcare system in Gaza comprises the Ministry of Health, United Nations Relief and Works Agency for Palestinian Refugees (UNRWA), non-government organisations (NGOs), military medical services and multiple private healthcare providers. Thirty-two hospitals provide secondary and tertiary services to a population of 1.82 million. During times of conflict, the Ministry of Health becomes the only emergency care provider. The Gazan health system is overstretched, lacks adequate physical infrastructure, supplies and standard training opportunities. The Israeli blockade and fiscal crisis have exacerbated these insufficiencies.
Power crisis and drug shortage
As the Palestinian inhabitants of Gaza continue to suffer from persecution at the hands of Israel, the end of 2017 has seen a growing medical crisis. The primary reason for this is the worsening shortage of drug supplies in Gaza’s major hospitals and clinics, and a power shortage that has had a catastrophic impact on the health facilities.
Health facilities in Gaza have been crippled by worsening power shortages related to conflict in the area. This power crisis has been ongoing since June 2006, following an Israeli military strike on a power plant in Gaza, and has significantly impacted healthcare delivery. Hospitals in Gaza use approximately 500,000 litres of fuel monthly to operate emergency generators for the provision of life-saving services. Power shortages severely restrict access to medical services, such as diagnostics and sterilisation, and the resulting delay in necessary surgical interventions is regularly life-threatening. The waiting time for elective surgery is now 48 weeks, as compared to the Gaza Ministry of Health threshold of 24 weeks.
The power supply, on average, lasts for 3-4 hours. Power fluctuations frequently result in damage to essential life-saving equipment. Additionally, over 150 essential machines are currently out of service or unavailable, including defibrillators, anaesthetic machines and items such as surgical drains, epidural catheters and surgical sutures. Functioning and well-maintained medical equipment are seen as a “luxury” by the critically ill. The head of the neonatal department at al-Naser hospital in Gaza recounts a horrific experience in the face of a power cut: “One of the most devastating times ever, we were rushing between the babies and alternating manual ventilation to take over the ventilating equipment for about 8 minutes. We were afraid to lose them.”
Regular power cuts lasting 18-20 hours lead to generators being overused, which then require either repair or replacement. However, such maintenance is practically impossible, as spare parts are on the “dual-use list”: a list of items which Israel suspects might be used for both civilian and military purposes. Currently, an additional $800,000 USD funding is required to repair generators.
Power shortages impair the collection, storage and transport of blood products. Storage of high quantities of donated blood at acceptable standards is currently a particularly concerning issue. An adequate supply of blood is a pre-requisite for emergency surgeries, managing blood loss after childbirth and for ongoing treatment of blood disorders. Gaza requires 35-40,000 units of blood annually, which increases by around 20% during periods of active conflict.
In November 2017, 43% of all drugs on the essential drugs list were completely exhausted, with particular shortages in cancer, psychiatric and ophthalmological drugs. A wide range of essential medical disposables, including syringes, line tubes, filters for dialysis and dressing materials were also in short supply. As of October 2017, 30% of the items on the essential disposables list were reported to be at zero stock levels.2
A financial crisis causing a clinical crisis
Plunging cash flow has led to multiple problems. Short supply of critical necessities, including life-saving drugs, IV fluids and surgical instruments, threatens patient safety and treatment capacity. During the 2014 Gaza War, Gaza’s largest hospital, Al-Shifa, ceased all planned surgeries, instead performing only life-saving emergency surgery. Even today in the Gazan health system, 30% of the medications required in intensive care are unavailable. In the southern district, oncological treatments have ceased due to the shortage of medicines. A lack of laboratory supplies has rendered haematological and microbiological tests completely unavailable in outpatient clinics, and accessible only to severely ill hospitalised patients. Sterilizing agents are in short supply, thus increasing the risk of contracting deadly infections. Similarly, the radiological department in Al-Shifa hospital has been made almost redundant due to malfunctioning CT and MRI scanners. The decommissioning of these machines is a result of budget limitations and spare parts supply. The latter has been severely restricted by the problems associated with obtaining Israeli permission to deliver spare parts.
Salary payments to staff have remained an issue throughout the conflict. Over the past 12 months, doctors who receive their salary from the Palestinian Authority in Ramallah have only received a quarter or half of their pay. Some staff members have been pushed to the point of sharing wages. However, despite a lack of adequate infrastructure, essential equipment and drugs, the staff at Al-Shifa continue to deliver the best possible patient care. The situation is particularly critical during Israeli military offensives when huge numbers of emergency cases push the hospital’s operational capacity to the brink of collapse.
Insufficient access to treatment and the dilemma of referrals
With a chronically overburdened health system that is confronted by conflict and financial misfortune, the struggle to manage an enormous volume of patients is inevitable. Such incapacity regularly necessitates referral to facilities outside the Gaza Strip. However, an increasing number of patients are finding that their referrals are delayed or rejected. Typically, access to hospitals in Israel or the West Bank is requested for patients requiring specific treatments not available within the Gaza system, or in cases where services, supplies or personnel are lacking. Patients who have their applications approved are subject to stringent Israeli security interrogation. In addition, 60% of patient companions have their permits either delayed or denied. Only 1 first degree relative is allowed to accompany the patient. From 2012 onwards, the approval rate for patient companions has steadily declined. Restricted access to Egypt due to the closure of the Rafah border terminal has further exacerbated these problems. No medical aid or personnel are allowed to access Gaza via Rafah during times of closure, typically extending for up to 3 months. Multiple families have suffered through mourning the death of their loved ones due to these travel restrictions. For example, in one such case, a 45-year-old lady, who was the mother of 9 children, died of breast cancer after her requests for a permit to seek treatment in a hospital in Jerusalem were rejected twice. Similarly, a 2-year-old patient with renal failure died while waiting for financial approval to be referred out of Gaza. To make things worse, securing a permit does not guarantee permission to cross the border, since the Israeli military at the border may deny access. Even if the referral is approved, the patient co-payment, accommodation for the accompanying relative, transport and incidental medical costs represent significant financial burdens for a population in which the unemployment rate stood at 41.7% in 2017.
Water supply and food shortage
Population growth, the conflict and the Gaza blockade all contribute to the exacerbation of water and food shortages. Currently, Gaza draws the majority of its water from a coastal aquifer shared with Israel. The rate of extraction exceeds that of regeneration, which has led to increasing salinization of the water, rendering 95-97% of the tap water unsuitable for human consumption. Indeed, all groundwater wells in Gaza fail at least 1 WHO standard for water quality. Conflict escalations often result in damage to the water supply. Repairing such damage is difficult, due to the blockade on construction materials, as well as a lack of funds. Power shortages have resulted in non-functional wastewater treatment facilities, with untreated sewage leading to increased pollution of the sea along Gaza’s coast. Without an adequate electricity supply to operate the 72 water wells and 10 waste pump stations in Gaza, drainage of untreated sewage and maintenance of an uninterrupted safe drinking water supply is a major cause of concern. Tap water is only accessible for up to 5 hours a day, and 300,000 cubic metres of poorly treated sewage is discharged daily into the sea, thus increasing the risk of water-borne diseases. Such water is unfit for consumption, meaning that the Gazan population must rely on water purchased from private vendors for drinking and food processing, further burdening a poor community. Pollution has already had medical consequences, with an increase in the number of diarrheal cases during the months of June and July last year among children under the age of 3.
With respect to food security, strict restrictions on food exports to Gaza have made 77% of the Palestinian population dependent on food distribution by World Food Program (WFP) and UNRWA. A declining economy and a decrease in per capita income have resulted in a vicious circle of poverty, food and health insecurity.
Mental health in Gaza
Epidemiological surveys have shown an average prevalence of 15.4% and 17.3% for PTSD and depression respectively among Gazans. Children inhabiting war zones are at a higher risk of developing PTSD and other emotional problems. Exposure to bombardment is the strongest predictor of developing post-traumatic stress reactions. The recommendations for improving mental healthcare in Gaza include specific training courses for psychotherapeutic interventions, maintaining a constant supply of psychotropic drugs and establishing well-equipped mental health units.
The role of the international community and health professionals
With the assistance of financial aid from organizations like the World Bank and countries around the world, organizations such as the UNRWA are playing a vital role in meeting the basic needs of Palestinians. UNRWA coordinates free food distribution, provision of shelter through refugee homes and construction of basic health infrastructure. Indeed, 70% of the population of refugees in Gaza are dependent on the UNRWA to meet their basic needs. The Palestinian community requires the assistance of global organisations, both in terms of finance and technical training, to become self-sufficient in the provision of healthcare. Increased funding to procure essential health supplies, including medicines and disposables, would facilitate improvements in healthcare provision, avoidance of referrals and prevention of delays. Funding should also go towards capacity building, in maintaining a reliable supply of essential equipment and training of health professionals.
As the crisis in Gaza continues to mount, assistance is required in all forms for Palestinians. As medical students, we might not qualify as members of an Emergency Response team, but there remain opportunities to engage with, and advocate for, the Gazan population, particularly with respect to healthcare. Foremost, raising awareness of the humanitarian crisis in Gaza should remain a priority. Volunteering opportunities for doctors are also available through organisations such as the Palestinian Medical Relief Society or Volunteer Palestine.
The Gazan health system is under an enormous strain due to decades of conflict. It is vital that humanitarian organisations and governments continue to advocate for increased funding and develop strategies for efficient implementation of health resources. Moreover, further peace talks are essential to improve Gazan health outcomes by facilitating improved cross-border transfer of patients and essential supplies.
Image 1: public domain, accessed from https://pixabay.com/en/palestine-gaza-strip-in-2015-678981/
Conflicts of interest
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