Introduction

Since Oct. 7, 2023 and until the date of this article, Gaza is still being subjected to air, sea, and ground bombardment in a cruel war targeting the lives of its residents and all aspects of their lives therein, including the destruction of infrastructure and buildings of all kinds, houses, apartments, water, and food, agricultural lands, roads, and all services, especially health services (hospitals and health centers), educational services (schools and universities), the economy, factories and shops, and the viable environment. They were subjected to systematic destruction, starting with the indiscriminate bombing of civilians, which led to the killing, wounding, and injuring of tens of thousands, and the expulsion and displacement of most of the population internally, not to mention the stifling siege that prevented the arrival of food and medicine, cut off water and electricity, and stopped the fuel needed to pump and desalinate water, treat wastewater, sewage and solid waste, and run bakeries, factories, means of transportation, and medical devices. The environment in Gaza also suffers from physical, chemical and biological pollution resulting from all sorts of ammunitions used in bombing, sewage mixed with drinking water and accumulated solid waste.

Public health in Gaza

The concept of health that we embrace is a broad concept that is not limited to physical health only, but also includes mental health, quality of life, suffering, and well-being, within the general context of life in the Gaza Strip in all its aspects. Therefore, it is important to realize that this war is not the first to target Gaza. The residents of Gaza in particular, and Palestine in general, have been targeted by the occupying State since it launched wars and sieges. Therefore, it is key to emphasize that the correct approach to understanding and analyzing the public health situation in Gaza cannot be undertaken without being cognizant of the political and social determinants of health. The most important of those determinants is the occupation, as a result of which most of the people of Gaza have been suffering for 75 years; the fact is that about two-thirds of the Gaza Strip’s population are refugees who were displaced from the occupied Palestinian territories in 1948 (the Nakba), then they were subjected to direct occupation in 1967 (the Naksa).

Two years following the exit of the occupation army and settlers and the dismantling of the settlements in 2005, that is, in 2007, the occupation imposed a complete siege on Gaza, which led to weakening the economy, mainly its two agricultural and industrial sectors, and preventing freedom of movement, to an extent it became similar to a large prison. This siege was accompanied by an impoverishment policy that limits the ability of the people of Gaza to work, farm, trade, manufacture, export and import, in addition to seven wars and invasions that began in 2008 and continued until January 2009, then 2012, 2014, 2019, 2021, 2022, and finally the current war in 2023-2024. These incursions resulted in killings, destruction, and intense exposure to violence, which affected physical and psychological health.

Public health indicators in Gaza before the October 2023 war

Although we will discuss in this article the conventional statistics of deaths, morbidities, and disabilities, our approach will not be limited to merely enumerating the numbers of dead, wounded, sick, bacterial infections, and chronic diseases, but rather goes beyond that to cover indicators of quality of life, wellness, and mental health as each of the subjective health indicators is equally important, such as the subjective assessment of quality of life or perceived suffering, and objective indicators, such as infant or maternal mortality rate. When reviewing the most important health indicators for the year 2022 in that narrow besieged coastal strip, which has an area of 365 square kilometers, a population of 2.166 million people, and a percentage of 66.1% of refugees and slightly more than 40% of children under 15 years of age in its demographics, good indicators are found, taking into account the long siege and successive wars. In 2022, the number of primary health care centers in the Gaza Strip was 159, of which 52 belonged to the Ministry of Health, 22 to UNRWA, 80 to non-governmental organizations, and 5 to the military medical services, in addition to 6 community psychiatric clinics. The number of hospitals reached 36 operating hospitals, including 16 general hospitals, 16 specialized hospitals, two physical therapy and rehabilitation centers, a maternity hospital, in addition to a psychiatric hospital (Ministry of Health, 2023). Gaza also had seven dialysis units serving 1,034 patients in 2022, and vaccination rates in Palestine, including Gaza, reached approximately 97%. As for infectious diseases, the number of reported cases of hepatitis A reached 84 cases, with a ratio of 3.9 cases per 100,000 people, and just over two thousand cases of cancer were diagnosed in 2022.

With regard to casualties, the total number of deaths in Gaza reached 6,061 cases. The infant mortality rate in Gaza was 10.8 per thousand live births, and the maternal mortality ratio was 17.4 per 100,000 live births, while the number of maternal deaths was only ten cases. The average life expectancy for males was 72.8 years and for females 75 years, while the total number of births reached 57,422 live births (Ministry of Health, 2023). As for the number of persons with disabilities, it reached approximately 58,0000, equivalent to 2.6% of the population of the Gaza Strip, according to a press release issued by the Palestinian Central Bureau of Statistics on Dec. 3, 2023 (Palestinian Central Bureau of Statistics, 2023).

A survey conducted on quality of life, human insecurity, and perception of suffering in the Gaza Strip before and after the 2008-2009 war showed a statistically significant increase in both feelings of insecurity and suffering after the war (Hammoudeh et al. 2013). The results are similar to another study that showed that the violence to which the people of Gaza are exposed during the ongoing war and siege is one of the causes of human insecurity (Ziadni et al., 2011). A qualitative study conducted in the occupied Palestinian territory confirms that chronic and acute exposure to violence and war resulting from protracted conflict across generations leads to a significantly reduced quality of life (Mataria, 2009). Another study conducted in the West Bank and Gaza Strip in 2011 showed that human insecurity and economic restrictions (the effect of the siege, for example) have a negative impact on health (McNeely et al., 2014). Researchers have been able to clarify that the impact of war and violence in Palestinian societies leads to social suffering, unlike the Western pathological diagnosis of post-traumatic stress disorder (Giacaman, 2018). However, despite successive wars, the imposed siege, and constant exposure to occupation violence, the people of Gaza continued to try to break the siege and build economic, educational and health institutions, achieving significant milestones, especially in the education and health sectors.

Public health indicators in Gaza during the October 2023 war

As previously mentioned, the systematic bombing and destruction had a severe negative impact on public health indicators in Gaza. The complete or partial destruction of more than 60% of housing units (OCHA-Reported Impact Day 107, 2024), led to the deaths of more than 26,000 within three months and 20 days of war, i.e. more than four folds the number of deaths in the entire year 2022. About 70% of them were children and women. More than 64,000 Gazans have been injured so far (Ministry of Health, 2024). It should be noted that an analysis of mortality data reported by the Ministry of Health in Gaza has proven to be accurate and reliable (Jamaluddine et al., 2023). In addition, 7,780 people were reported missing under the rubble, all of this while 21 out of 36 hospitals were completely out of service, and 15 hospitals still providing partial services (only 42%), in addition to four field hospitals that were fully operational. As for primary health care centers, the World Health Organization states that only 19% of them are still providing services, noting that the occupancy rate of hospital beds reached 409% (World Health Organization, 2024).

Gaza suffers from a severe shortage and pollution of water, an acute shortage of medicines and medical supplies (anesthesias, antibiotics, intravenous fluids, pain relievers, and insulin), blood and its derivatives (World Health Organization, 2024), as well as disinfectants and sterilizers, the inability to access health services, including vaccination and vaccines for children, and the inability to preserve vaccines in the cold chain due to the lack of electricity, which caused a major collapse of many components of the health system. The remainder of this system, such as health and medical services, was busy dealing with emergency cases of wounded people, victims of bombing. The impact of these health and environmental problems is compounded by population overcrowding resulting from the forced internal displacement of the population of the northern and central Gaza Strip to the south, even within the areas of the Gaza Strip, which is estimated at 1.7 and 1.9 million, i.e. between 75-85% of the population of the Strip (World Health Organization, 2024; UNRWA, 2024). Indicators of deteriorating public health have begun to appear, such as increased cases of respiratory diseases, diarrhea, intestinal infections, hepatitis, and lice. Respiratory infections are expected to increase, in particular, during this winter season with overcrowding. Intestinal epidemic infections are also expected to increase with the continued shortage of clean water and personal hygiene supplies.

As for infectious diseases, and in view of the hazardous environmental situation, the contamination of drinking water, and its harmful health effects, a sharp increase in cases of jaundice has recently been observed, jumping to more than 7,400 cases, an important part of which is likely to be the result of hepatitis type A, which is usually transmitted through contaminated water (World Health Organization, 2024). Infectious diseases are now widespread, especially diarrhea and upper respiratory infections. As of Jan. 22, 2024, more than 159,000 cases of diarrhea have been reported. These cases include more than 84,000 cases of diarrhea among children under the age of five. This represents a 23-fold increase over the number of infections in 2022, more than 225,000 cases of acute respiratory infection, about 70,000 cases of scabies and lice, more than 44,000 cases of skin rashes, and more than 6,600 cases of chickenpox (World Health Organization), 2024).

As for non-communicable diseases, more than 350,000 patients do not have access - or have little access- to medicines and medical services, including 225,000 who suffer from high blood pressure, 71,000 people who suffer from diabetes, 45,000 who suffer from cardiovascular diseases, and about 10,000 cases of cancer. Approximately 2,000 cancer cases are diagnosed annually, and there are 1,100 dialysis patients, among others. In addition, more than 485,000 people suffer from psychological and mental diseases and disorders, a large part of which is due to severe daily psychological pressures, including bombing and the inability to provide basic life needs (World Health Organization, 2024).

Food insecurity also poses a major challenge to the health status of Gaza's 2.2 million population, including children and pregnant women. Organizations concerned with food security have reported that Gaza faces “catastrophic levels of food insecurity,” and that 93% of the Strip’s population suffers from hunger at unprecedented levels (World Health Organization, 2023). About 378,000 are in the Phase 5 of catastrophic hunger, food shortage, and the loss of the ability to adapt to the food situation, in addition to about 939 thousand people in Stage 4 of food insecurity, that is, the emergency stage, according to the combined food security classification (World Health Organization, 2024; OCHA Flash Update #100, 2024). International organizations active in the field of food provision can only meet a limited portion of food needs if immediate and comprehensive measures are not undertaken to provide food.

Disabilities are expected to increase sharply with the huge number of wounded and injured. According to the Euro-Mediterranean Human Rights Monitor’s estimate, at least 5,000 war-wounded people in Gaza suffer from very serious disabilities, as published in the Monitor’s press release on Dec.7, 2023 (Euro-Mediterranean Human Rights Monitor, 2023). Besides, the major psychological impact of what the residents of Gaza were exposed to has not yet emerged clearly and completely. All community mental health centers have been closed and have run out of medicine, and the only hospital for mental diseases has been bombed and is out of service (Jabr & Berger, 2023). The massive loss of life and livelihoods, the destruction of homes and institutions, and the deprivation of basic needs will all affect mental health for a long time. Hence the need to make a clear effort to return to normal life, rebuild houses, provide water and food, and ensure that mental health is not overlooked and that all its aspects are covered in a comprehensive health strategy. This strategy should also meet the need for mental health care and provide psychological support (Najem et al., 2024, unpublished), provided that psychological support would mainly rely on group and community interventions that are appropriate for our societies rather than individual interventions. The same applies to children, as it is preferable to use a group approach to recovery (Jabr & Berger, 2023).

One of the most important effects of the war on public health in Gaza is the large increase in the number of deaths directly resulting from the war (bombing, shooting, etc.), and indirectly resulting from infectious and non-communicable diseases and the lack of health care as a result of the destruction of the health system, as well as due to the lack of health care for babies, mothers, and newborns in particular. There are approximately 52,000 pregnant women in Gaza, and an increase in the number of miscarriages and stillbirths has been observed (Elnakib et al., 2024; Checchi et al., 2023). The burden of infectious diseases has increased significantly, and epidemic outbreaks have swollen in frequency and severity. The burden of non-communicable diseases and their complications is expected to increase, nutritional status will deteriorate, and diseases related to malnutrition and their resulting complications, complications resulting from the unavailability of medicines and treatment for a long period, and deterioration of mental health will intensify (Checchi et al., 2023).

Physical injuries and disabilities resulting from war, illnesses and psychological stress resulting from exposure to the ravages and traumas of war, the death and injury of relatives and loved ones, and a sense of loss should also constitute a top priority in any response plan and efforts to rebuild health services in Gaza, given that the huge number of adults and children with disabilities will represent a major burden on the health, economic and social system in Gaza. Alleviating this burden and meeting this growing need for specialized care requires providing basic services to those affected and their families in terms of treatment, psychological and social support, and assistive devices for the disabled, as well as integration into different aspects of life (Najem et al., 2024, unpublished). Particular attention must also be paid to children who have lost their families and become orphans. Their physical and psychological needs must be provided for, which requires a special effort in identifying these children, ensuring that they are provided with housing and fed, helping those who need to get dressed, educating them as normally as possible, perhaps considering reuniting them with remaining relatives if possible, and providing the required financial support. This also applies to elderly people who have lost their dependents and caregivers.

Summary and recommendations on public health priorities in Gaza

In short, Gaza is now in real, urgent and immediate need for all necessities of life, which were destroyed in the war. The first priority, which is considered a precondition for implementing any successful and effective measures or interventions to preserve life and health, is to stop the war on the Gaza Strip, withdraw the occupation army, lift the siege, and allow freedom of movement. This will enable the necessary interventions to save the population and preserve their lives to be implemented, and then attention will shift to the remaining key priorities, mostly:

First, providing clean water suitable for drinking and human use. For instance, there is no clean water acces at all in northern Gaza, while in southern Gaza, children receive 1.5 to 2 liters of water per day, which is less than the minimum required for their survival, i.e. 3 liters. It is noteworthy that the minimum amount of water needed in emergency situations is 15 liters per person, which includes drinking, washing and cooking water, according to international humanitarian standards (World Health Organization, 2024; OCHA Flash Update #93, 2024), This is done by re-pumping pipes cut from occupied Palestine in 1948 (OCHA Flash Update #97, 2024), and repairing wells and water purification plants. The sanitation infrastructure also needs to be rebuilt in the medium term and repaired in the short term. Fuel for water pumps and wastewater treatment must be allowed in, as well as the unconditional entry of equipment needed to repair wastewater and drinking water refining and treatment plants. The same also applies to solid waste management.

Second, the unrestricted entry of food of all kinds, in quantities sufficient to meet the needs of the population, the presence of an appropriate strategic stock, the return of farmers to their lands and immediate assistance provided to them with seeds, fertilizers, agricultural pesticides and irrigation water.

Third, freedom of movement for Gaza residents, mainly allowing the wounded and sick, whom the health system cannot help in its current state, to seek treatment abroad, in Jerusalem and the West Bank.

Fourth, the unrestricted and unconditional entry of medicines and medical equipment in necessary quantities, building a strategic stock thereof, storing them in a decentralized manner, and allowing the entry of volunteers from health and medical teams from all over the world to support the health system, knowing that Gaza has experienced and qualified health human resources, including public and community health workers. It is crucial to take advantage of this and mobilize resources to support them in implementing all public health functions to maintain a resilient health system in the present times and in the future. It is necessary to work with health service providers in Gaza to conduct a rapid need assessment, exert pressure to allow the entry of all necessary supplies and equipment and volunteer specialist health human resources, including specialists in war medicine, psychiatry and others, and to resume human resource training in public health and epidemiology in Gaza. This include local volunteers who are currently playing an important role, in order to adapt to the current situation and needs. It is also important to immediately reopen and operate all hospitals, primary health care centers and rehabilitation centers, restore them and compensate for the lost equipment, equipment and human resources.

Fifth, introducing in-kind assistance, especially with regard to providing shelter in the form of prefabricated homes and tents that provide the minimum level of adequate housing and related services, provided that these shelters are established in cities, villages and camps in the original residential places of the internally displaced to enhance community solidarity among the population. This should be accompanied by the rapid restoration of schools, the provision of classrooms as temporary alternatives to what was destroyed and demolished, and the resumption of studies as soon as possible, especially for the primary grades, to facilitate the return of children to their normal lives. This includes strengthening health education and social and psychological guidance in schools.

This situation must put everyone before their responsibilities, - most notably the occupying State that is causing this chronic suffering-, the superpowers, the influential countries in the Eastern Mediterranean region, and international organizations, mainly the Security Council, the United Nations and its institutions, specifically UNICEF, the World Health Organization, and UNRWA. We must not remain silent about the continuation of the war and persevere in accepting the siege. The necessary support and funding must be provided to the Ministry of Health, the United Nations and international institutions, as well as non-governmental organizations to resume their services, which have been completely or partially halted in northern Gaza, and which have been reduced in a way that does not meet the basic needs in southern and central Gaza. We need to work to meet the needs of residents within the proposed recommendations and under a permanent ceasefire.

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