The Israeli army has, since October 7, been waging a destructive war on Gaza. Thousands have been killed or injured, many are left destitute and without shelter and there are thousands of displaced persons who face extreme hardship and live under inhuman circumstances. The war has caused an unprecedented human catastrophe, a total breakdown in infrastructure, and the complete destruction of civilian institutions, leading to disastrous consequences that affect the ability of the population to live and survive. In this war, the health system, both its installations and its personnel, have been deliberately and directly targeted. It became quite clear from the very first moment that the war on the health system was an essential part of Israel’s war strategy against Gaza, and that medical establishments such as hospitals, primary health clinics and their personnel were all potential targets, in total disregard for international humanitarian law, especially the fourth Geneva Convention which clearly affirms respect and protection for workers in the medical ad heath sectors who provide care for the wounded, the sick, the elderly and pregnant women. That Convention urges all parties to a conflict to respect and at all times to protect all medical and health installations, as also transporting the wounded, the sick and the physically disabled.
A mere two days after the start of the war the Bayt Hanun Hospital in north Gaza was made to cease its operation. This was followed by an order issued by the Israeli army to clear hospitals of the sick and medical personnel and abandon all medical facilities in Gaza and its northern region. This order was rejected by workers in the heath sector who insisted on continuing to provide medical and emergency services. The population was driven southwards in an attempt to evict them from Gaza while at the same time the Baptist Hospital was bombed and other hospital areas were besieged and shelled, including al-Shifa’, the largest hospital in Gaza, as also the al-`Awda and the Indonesian hospitals and others. This represented persistent tactical attempts to empty all hospitals and health clinics and to force the population to leave and eventually be evicted. Under intense Israeli pressure and unceasing acts of repression as well as arresting medical staff and targeted shelling, medical personnel working in these centers were compelled to leave and the services they provided were drastically reduced. This knocked out the medical system in Gaza and its northern region where hospitals constitute the essential element in medical care and serve more than two-thirds of the population, with specialized medical care not easily available anywhere else in the Gaza Strip because of the presence of specialists and advanced medical equipment and treatment.
The war on hospitals and health clinics continued throughout the Gaza Strip. Threats, evictions and direct shelling of hospitals or their immediate surroundings went on, snipers targeted their workers, and ambulances carrying the sick and wounded were prevented from circulating, and later on more hospitals were surrounded. Orders issued by Israeli leaders not to allow into Gaza any water, fuel, electricity, food, medical supplies, and the internet had a catastrophic effect on Gaza’s hospitals and clinics, rendering them unserviceable and in a state of complete paralysis, where they no longer could cope with the rapidly intensifying emergency or with the basic medical and heath needs of the population.
At later stages, the Israeli army continued to target medical installations in other regions of Gaza following the same tactic in waging war on the health system, intending to undermine and paralyze it to render it incapable of providing its services. This was part of the army’s and the Israeli government’s strategy to end all that sustains life for the population by waging war on the health sector and destroying or paralyzing it. It is worthy of note in this regard that this onslaught on the health system was blessed and fully supported in a famous letter signed by noted Rabbis who called on Netanyahu to bomb hospitals. This was followed by another letter signed by hundreds of Israeli doctors in an unprecedented violation of medical ethics, basic principles of humanity and international law. Up until the moment of the present writing of this paper, reports by the WHO and the Ministry of Health indicate that the consequences of this brutal war being waged on the medical and health system has led to the closure of 20 hospitals and only 16 hospitals remain open and operate at three times their absorption capacity without being able to cope with the ordinary health needs of the population since its operational capacity has drastically declined for lack of medical supplies and of water, electricity, fuel and medical staff. These hospitals face the challenges arising from a drastic shortage of medical staff, including specialized surgeons, nerve surgeons and personnel working in intensive care units, to say nothing about the lack of medical supplies. They very urgently need fuel, food and drinking water. Occupancy in these hospitals has reached more than 350% and 250% in intensive care units, all of which presents an unprecedented challenge for the efficacy of medical services, their quality and their ability to respond properly to the suffering of the population. More than 94 medical installations have been either severely damaged or destroyed along with more than 83 ambulance cars in this ongoing assault on the health sector, and more than 59 primary health clinics have ceased to function, and only 14 are left to offer services in southern Gaza and some areas of central Gaza. Medical and heath teams have suffered more than 300 attacks leaving 377 dead members of medical teams and some 764 of them wounded, in addition to the arrest of about one hundred medical workers.
This horrifying situation, unprecedented in recent human history, leaves the health system on the verge of total collapse if urgent and necessary measures are not taken, the most important being to end this onslaught on the health system and adherence to international conventions such as the fourth Geneva Convention and other international laws and conventions, in addition of course to ending the war itself and all military assaults in general.
The collapse of the health system, Israel impeding access to clinics and hospitals, the lack of medicines and medical supplies, the difficulty of conducting clinical examinations, and the breakdown of all preemptive and palliative programs have all severely impacted patients suffering from non-communicable diseases. Before the war, these patients had constituted an already heavy burden on the health system in providing medical services to more than 350,000 patients with heart problems such as heart attacks and cerebral apoplexy, high blood pressure, cancers, and chronic respiratory diseases such as chronic lung obstruction, asthma and diabetes, these being the main causes of death and illness in the Gaza Strip. It is likely that these medical conditions will grow worse in severity and complexity since more than 80% of these patients have no access to basic medicines and will not, in the foreseeable future, be able to obtain the essential follow-up care and needed palliatives, leading to aggravation of their condition and eventual death. It is quite certain that the rate of death, permanent injury and incapacity will multiply among these patients, stretching further the capacity of the health system once it recovers. Furthermore, the ability to control signs of danger, change life habits and to conduct early checkups are all complex matters which cannot be dealt with under present circumstances such as population transfers, lack of food and water, the degradation of the environment as a result of war and destruction, and the incapacity of the health system and its paralysis. The emergent and catastrophic humanitarian situation will doubtless exacerbate illnesses and put in danger new sectors of the population.
In this regard, kidney dialysis patients, numbering more than 1200 individuals, 40 of whom are children, are facing death or other health complications now that most hospitals which provided that treatment have closed down while the capacity of remaining hospitals to provide their services to these patients is gravely diminished due to lack of electricity and water as well as the lack of all needed materials for kidney dialysis. To all this must be added the lack of access to hospitals by these patients due to their eviction from their homes and the absence of the means of transport resulting from the constant Israeli shelling of hospitals and roads.
In the face of all these daunting challenges, the hospitals still running which provide kidney dialysis have been forced to curtail treatment sessions and available days in order to deal with patients waiting in line to obtain dialysis, exposing many of them to slow death. Many such deaths have been recorded, the result of the inability of patients to obtain these treatments at the proper time.
Cancer patients, numbering more than 2000, face similar dangers, and they have been taken away from hospitals under bombardment. Thus, the Turkish Friendship Hospital specializing in cancer patients suffered direct shelling in November, threatening the lives of patients undergoing treatment and in a grave state of health. Furthermore, cancer patients suffer from lack of appropriate medicines which Israel prohibits from entering Gaza while many have been prevented from leaving Gaza to receive needed treatment abroad.
Patients with chronic obstructive pulmonary disease (COPD), and to a lesser extent patients with asthma, are suffering from exposure to the dust rising from the bombing, and these do not receive immediate treatment. Patients with diabetes, high blood pressure and heart conditions, numbering more than 250,000, face unprecedented threats to their lives due to lack of treatment, the necessary medical follow-up, and medical tests. This is especially the case with diabetics who basically depend on Insulin, the lack of which will not enable them to survive. This is especially true of Type 1 diabetics estimated to be about 2000, including children. It is likely that the rate of deaths and permanent disabilities will multiply among these patients, a result of complications of the disease and the lack of treatment. In turn, this will not only largely prevent the proper treatment of non-communicable diseases as a feature of permanent development but will also increase the rate of diseases and of disabilities and deaths.
Officials in the Palestinian Ministry of Health, the UN organs and national and international agencies have all confirmed that communicable diseases are ravaging the population of the Gaza Strip. Despite the collapse of the system that monitors epidemics and its inability to observe epidemics and gather data from all regions of the Gaza Strip, there is general agreement that communicable and epidemic diseases are ravaging Gaza at an unprecedented scale and at a horrifying rate when compared to the pre-war situation, exceeding that previous situation by four to five times. This is due to lack of drinking water, the lack of food, the absence of collective immunity, the lack of medicines and detergents, population movements, overcrowding in shelters, degradation of the environment, and the destruction of infrastructure and sewage treatment stations leading to water pollution of water that is already of low quality. It is estimated that the burden of these illnesses will increase as the environment is further degraded and as babies, children and mothers receive bad nourishment. With time, it is feared that other pathogens will be introduced, causing other diseases and leading to further epidemics. Since the start of war, the number of cases of patients suffering communicable diseases is estimated at half a million, including skin diseases, upper respiratory track inflammations, epidemic kidney inflammation, meningitis, dysentery, diarrhea, and other conditions, all of which can eventually lead to the death of large numbers of children, equal to or exceeding the number of those already killed by Israeli bombardment. It is expected that tuberculosis will return at a higher rate due to overcrowding, weak collective immunity, malnourishment, and the degradation of living conditions.
The immunization scheme for Gaza’s children was part of the national Palestinian program which had achieved a percentage rate reaching 99%, has contributed to control communicable diseases related to immunization among children and to limit their spread. But is feared that all these efforts and achievements will face numerous challenges and failures due to this barbaric war on Gaza. Most pertinently is the disappearance of two-thirds of the primary health clinics that provide immunization and the lack of security and safety to access the working clinics under these terrible circumstances. Furthermore, the dispersal of the population and the possibility of following them up or contacting them, the provision of immunization and making sure that cooling is adequate to preserve it, plus achieving a high rate of immunization to preserve communal immunity are all things that are essential for the success of immunization programs and preventing recurrence of diseases such as measles which is expected to spread under these circumstances as also other diseases which had been under control. Causing real anxiety is the ability to maintain a high rate of immunity which would enhance communal immunity since there are several regions in Gaza and in its northern areas where children have not been immunized for more than three months. The Juzoor Institute for Heath and Social Development was able, up till the time of this report, to immunize around 2500 in Gaza’s northern regions but the challenge still remains because of the factors mentioned above, and because many pockets in Gaza are still unsafe and where children cannot receive the needed immunization.
The greatest challenge in Gaza is acute malnourishment which occurs when people cannot obtain the vitamins and minerals, iron and proteins that allow the body to perform its normal functions. The population of Gaza face the threat of famine since more than 90% of the population of the Gaza Strip, some 2.2 million people, are threatened with “severe malnutrition” while one quarter suffer from “catastrophic rates of hunger” now in danger of severe malnutrition worse than the pre-war situation. In such a case, the children are more likely to die. “Systemic restrictions” are in place to prevent aid reaching northern Gaza. The UN Office for Coordinating Humanitarian Affairs stated that Israel allowed only one quarter of aid convoys scheduled to be delivered, i.e. some 30% of what is needed. According to UNICEF, more than ten thousand Gazan children are in danger of abnormal weight loss in the coming weeks, this being one of the most dangerous consequences of malnourishment which can affect growth and brain function and can lead to weak immunity and death. Various data indicate that children are being born ill to mothers who suffer from malnourishment, that babies are losing weight, that mothers with dry breasts can no longer nurse their babies normally, and that these babies are so weak with hunger that they cannot fight infection. All these things will leave a deep immediate and long lasting health consequences on Gaza’s population, especially on the vulnerable sectors like children, women, pregnant women, the newly born and the elderly. This will result in a rising rate of infectious diseases, anemia, molecular elements of nourishment, nutritional dwarfing, and death.
The psychological impact of the war as a result of the killing, the scenes of the dead and wounded, the widespread rubble and deprivation from basic necessities is beginning to spread on a large scale among the population of Gaza, starting with health workers, then women, the youth, the elderly and the children. Reports by the UN Office for Coordinating Humanitarian Affairs in Occupied Palestinian Territories (OCHA), the Palestinian Ministry of Health, the World Health Organization and reports by diverse other bodies indicate a rampant and dangerous increase in the rate of psychological trauma and diverse types of mental disturbance such as depression, anxiety and nervous tension all of which had been there in the pre-war period at a diminished rate but which has now reached epidemic proportions affecting two thirds of the population. This is especially the case with children suffering from “severe psychological traumas” with symptoms such as “panic, nervous agitation, spasms, aggressive behavior, bed wetting, and clinging to parents.” All the above organizations affirm that the psychological and mental consequences will be long lasting and that post traumatic stress disorders (PTSD) will inevitably occur especially in the absence of palliatives like the treatments for severe psychic conditions and measures to cope on the societal level. This will result in psychic and bodily disabilities, impacting emotional relationships and the ability to have a positive attitude towards the present and the future, and leading to an inability to construct any heathy vision of the various aspects of life and the creation of many psychic and mental disturbances such as depression, phobias, panic attacks, involuntary urination, and nightmares. All these conditions will have an impact on the future social life of Gaza’s population and on their human behavior, requiring widespread, systematic, and wholesale programs of psychological treatment and the training of teams of highly qualified and professional psychological workers to deal with these challenges.
Pregnant women, children, infants and the suckling bear a burden both complex and unimaginably painful, not just as victims of shelling, killing and destruction or because of dispersal, lack of food and medicines and collapse of water and electricity supplies but also because women bear the added burden of pregnancy and delivery. It is estimated that there are 55,000 pregnant women in Gaza and more than 180 daily deliveries. In all probability, these women are unable to access the greatly needed medical attention during pregnancy and delivery since most health facilities are no longer able to provide any services or because they are unable to reach clinics or hospitals, not to mention degradation of their nutritional, psychological and bodily conditions. This places them in the danger zone of pregnancy which could lead to a spike in the rate of deaths among mothers and the newly born. Tens of women have miscarried and the rate of premature delivery has increased three or four-fold. Many cases have been reported of early placenta abruption which can lead to death without immediate medical treatment. Lack of blood and plasma has forced doctors to perform hysterectomy as a way of treatment. Women put their lives in danger during delivery and submit to Caesarian and emergency operations without sterilization, anesthesia, or pain killers, increasing the chances of illness and death among mothers. The situation is even more dire in northern Gaza while in the south there is a large influx of pregnant women who had been driven out of Gaza and the north and now are overcrowding the maternity wards of hospitals that are still functioning. However, treatment is given to the most dangerous cases while medical staff is forced to discharge mothers within three hours after caesarian section. This causes other women to deliver wherever they shelter or in unsafe and unhygienic locations, increasing the danger to their own health and the health of the newly born.
This grim state of affairs reflects itself on the newly born. According to UNICEF reports, some 20,000 babies have been born since the start of the war and until the present writing, among whom hundreds are born prematurely. This is defined as occurring three weeks before the expected date of delivery and with sub-normal weights and sizes. Premature birth often renders the infant exposed to medical conditions requiring specialist care.
The fact that these newly born have no access to needed medical care exposes them to stunted growth or disability which can lead to death and this has led to a spike in the rate of infant mortality since the right treatment is unavailable and there is a lack of incubators, medicines, and nourishment. To be noted is the fact that many hospitals are no longer functioning while the lack of electricity and fuel have severely restricted the absorptive capacity of incubators as demand for them soared, thus denying necessary medical care to premature babies. Several babies share the same incubator or have been discharged before receiving adequate care in order to accommodate other infants with more serious problems. This grim and abysmal situation has no doubt doubled the rate of deaths among mothers and infants. According to various reports by international and local organizations the rates of deaths among mothers and the newly born are considered among the most significant indicators of health in a society. One might add that there is very great difficulty in obtaining accurate figures that reflect this suffering due to the inability of the medical monitoring system to follow developments due to other preoccupations connected with the ongoing war, thus making it necessary to activate other monitoring mechanisms during war.