The First International Conference to Rebuild the Health Sector in Gaza (Amman, February 7-8 2024) brought together a diverse international delegation of medical and health professionals and policy makers, with a focus on Palestinian organizations and voices, to draft a plan for rebuilding health in Gaza. As part of this effort, a public health sub-group was formed to ensure the adoption of a comprehensive public health approach and the embedding of community and population health as a core component of this plan. In this paper, we share the sub-group’s contribution to the conference.
Gaza is the most densely inhabited place on earth, with 2.2 million people, two-thirds of them refugees, living in an area of 365 km2. It has been under Israeli siege for more than 15 years and the victim of repeated Israeli military assaults in 2008, 2012, 2014, and 2021 (Reuters, 2023). A 15-year old adolescent living in Gaza today has witnessed five devastating Israeli wars since their birth, approximately one every three years. On October 7, 2023, Hamas launched armed incursions into the Gaza envelope, leading to the death of about 1200 civilians and military personnel, and the kidnapping of more than 250 people. On October 8th, Israel started a revenge assault on Gaza killing close to 30,000 civilians, and injuring and maiming more than 70,000, mostly women and children to date (WHO Health Cluster (updated daily), 2024; Euro-Med Monitor, 2024).
In violation of international humanitarian law, Israel has carried 744 attacks against Health care in Gaza (WHO SSA, 2024), targeting hospitals and primary health centers, rendering at least two third partly or totally dysfunctional and killing more than 377 health professionals (WHO Health Cluster (updated daily), 2024; ICRC, 2023). By November 2023, the current war had already become the deadliest war in history for UN health personnel (UN(b), 2023). The Israeli assault on Gaza also purposefully targeted the socioeconomic infrastructures (water, wastewater, roads, telecommunication), schools, religious sites, and residential and commercial units to force people into displacement and rob them of safe shelters and basic needs for survival. The devastation inflicted on the population is further compounded by the siege imposed on Gaza, restricting the flow of medical supplies, equipment, and essential resources necessary for the humanitarian response. Food, water, medicine, and fuel are being used as weapons of war. This deliberate use of hunger as a tactic in warfare by Israel is a severe violation of international humanitarian law, explicitly prohibited in the Geneva Convention (IHL Databases, n.d.). The enormity of these atrocities prompted South Africa in December 2023 to file a case against Israel at the International Justice Court accusing it of committing genocide.
Calls for an immediate ceasefire and a permanent solution to the occupation of Palestine are on the rise, although still resisted by Israel and some of its North American and European allies. Discussions of the ‘day after’ are ongoing, mostly on political issues but also on the rebuilding of health in Gaza. However, plans to address population and community health after wars tend to take a purely biomedical approach, and focus on rebuilding of hospitals and providing direct medical care. This effectively marginalizes the critical role of public health as a necessary precondition to health. A public health approach is community-based and primary health care-focused, while also attending to the social, economic, and political determinants of health that are necessary for wellbeing.
This paper acknowledges the need to address urgent medical needs and argues for the primacy of a public health approach to rebuilding health in Gaza- an approach that respects the history and strength of the pre-2023 war public health system and the expertise, experience, and competence of local public health professionals. This holistic view is particularly relevant in Gaza now, where the impact of the conflict extends beyond physical injuries to encompass a broader spectrum of mental and social health as well as economic livelihood and environmental issues.
The paper puts forth a vision for rebuilding health in Gaza with an emphasis on a public health approach. The paper consists of six sections. The first presents the holistic definition of health. The second and third describe the public health system prior to October 7, 2023; and discuss the role of the extant public health system in supporting the survival and resistance of Gazans. The fourth and fifth sections argue for a comprehensive and interconnected public health approach including a centering of values, to rebuilding health in Gaza. The final section suggests post-war priorities.
- Holistic definition of health:
The World Health Organization (WHO) defines health as: "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (WHO, 1946). This definition highlights the limitations of solely focusing on disease absence and emphasizes the need to address broader societal and environmental factors that influence well-being.
Physical health, the foundation of this holistic tapestry, encompasses factors like healthy nutrition, regular exercise, and quality sleep (Defense Health Hub, n.d.). However, public health initiatives increasingly recognize the profound interplay between mental, emotional, and physical well-being. Studies have shown that chronic stress, loneliness, and depression can contribute to the development of chronic diseases such as heart disease, stroke, and diabetes (SAMHSA, 2023).
Social health, often overlooked in traditional public health models, is now recognized as a crucial determinant of overall well-being. Strong and supportive social connections, nurtured within families, friendships, and communities, provide invaluable social support, a sense of belonging, and a buffer against stress (APA, 2020). Conversely, social isolation and loneliness have been linked to increased morbidity and mortality rates (Holt-Lunstad et al., 2017).
This shift towards a holistic public health approach has significant implications for interventions and policies. Public health initiatives are now moving beyond treating individual diseases and instead focusing on promoting healthy environments, fostering social connections, and addressing the social and economic determinants of health (WHO(a), 2023).
- Role of the Public Health system in supporting the resistance of Gazans since the October 8th Israeli war - A collective community strength and a resilient health system:
The recent escalation in the war against Gaza, spanning the last five months (October 2023 onwards) has inflicted immense suffering on the population. Yet, amidst the destruction and despair, a remarkable story of steadfastness (soumoud) unfolded. The primary healthcare system, deeply rooted in the community and boosted by a pre-existing emergency response setup and international and national coordination, emerged as a cornerstone of resistance, offering a lifeline to Gazans during this period of immense hardship. This resilience was not solely driven by healthcare professionals but by the collective spirit of the entire community, including journalists who played a crucial role in documenting and amplifying the voices of the affected (UN(a), 2023).
The primary healthcare centers (PHCs) in Gaza served as the first line of defense, staffed by familiar faces from the Gazan neighborhoods who had built solid ties with their communities and strong relationships with members of the population. This fostered a sense of trust and social support, critical elements for coping with the psychological trauma and physical injuries inflicted by the war. From providing timely trauma care to managing chronic conditions and offering mental health support, the public health system shouldered a significant burden, often operating with limited resources and under challenging conditions with only 66% of health facilities, including PHCs and hospitals, functioning by the end of October 2023 (OCHA, 2023). During continued hostilities, the health situation in Gaza reached its worst point in history, with 98 healthcare facilities, including 27 out of 36 hospitals, affected by the constant Israeli attacks by February 9th, 2024. This significantly limited access to healthcare services and led to a high number of deaths from citizens and healthcare workers (Relief Web, 2024).
Years of experience navigating attacks by Israel have equipped Gaza's health system with an effective and adaptable emergency response network supported by national and international efforts (WHO, 2018 & UNICEF, 2019). This pre-existing emergency response setup – developed over decades of exposure to war - proved invaluable in ensuring rapid response to the current emergency. Established protocols and communication channels, as well as regular collaboration between the Palestinian Ministry of Health, UN agencies including UNRWA, and humanitarian organizations like Médecins Sans Frontières (MSF), and the International Committee of the Red Cross (ICRC) ensured that health teams could swiftly mobilize and provide care to those affected by the violence (OCHA, 2023). Primary healthcare centers, hospitals, ambulance services, and humanitarian organizations worked in close collaboration, sharing resources, information, and expertise to optimize care and resource allocation to the affected communities and individuals. This coordination, ensured that even amidst the chaos, essential medical supplies reached those who needed them most, and patients were efficiently referred to higher levels of care when necessary (UN, 2024).
However, the story of resilience extends beyond primary healthcare systems and healthcare professionals. Ordinary Gazans with no previous health experience, rose to the occasion, volunteering to support health and medical teams, deliver aid, and provide emotional support to their neighbors. Journalists, risking their safety, documented the war on Gaza and brought the plight of the Gazan people to the attention of the world, especially highlighting the struggles of the health system. Their courage and dedication served as a beacon of hope and a testament to the unwavering spirit of the community (UN(a), 2023 & Zerrouky, 2023).
Despite this impressive display of community strength, steadfastness, and coordination, the Israeli attacks inflicted significant damage on Gaza's public health system. Community response was severely hampered by the continuous attacks on health infrastructure including facilities, personnel, ambulances, patient warehouses, and supplies. Between October 7th, 2023, and January 16th, 2024, 628 attacks were carried out in Gaza and the West Bank, (all in violation of international law) (WHO SSA, 2024). Bombing of healthcare facilities and the destruction of infrastructure posed immense challenges (Palestine Chronicle, 2023). However, the immense dedication of healthcare workers, coupled with the unwavering support of the community, international organizations, and journalists, ensured that healthcare services continued to be provided. This collective effort stands as a testament to the indomitable spirit of the Gazan people and the power of unity, collaboration, and heroism in the face of adversity.
- Gaza’s Public Health before October 7, 2023: Strengths and Weaknesses
The public health system in the Gaza Strip, before the onset of the war, grappled with intrinsic challenges significantly exacerbated by repeated aggressions by the Israeli government, and an ongoing 16-year land, air and sea blockade by Israel, rendering Gaza the world’s “largest open-air prison” (Farhat et al., 2023). The trajectory and transformation of emergency response structures were profoundly influenced by the cyclical nature of conflicts, particularly in phases of the major assaults mentioned above. These aggressions which inflicted direct and intentional damage on healthcare infrastructure have affected access to healthcare services for Palestinians in Gaza. In addition, the blockage/siege has restricted medicines and medical equipment from entering Gaza, affecting the ability of health care centers and hospitals to meet the need of their communities (Farhat et al., 2023). This led to the development of emergency response mechanisms to adapt to evolving challenges. Repeated attacks on Gaza compelled the emergency response structures to cultivate flexibility and resilience as survival mechanisms. The urgent need to respond swiftly to an influx of casualties and address the healthcare needs of the population during crises provoked significant adaptations with the support of international parties (WHO, 2018 & UNICEF, 2019). However, resource shortages, including critical medical supplies and personnel, persisted and worsened as the blockade continued, adding complexity to the already strained infrastructure and impacting access to comprehensive healthcare (UNICEF, 2019). The prolonged nature of the situation has also taken a toll on the mental health of both the population and healthcare professionals (OCHA, 2020; MSF, 2022).
Way before October 7, 2023, Gaza's public health system navigated a complex situation. On one hand, a young population, with the leading age group being under 19, offered great potential for future generations, and on the other hand, it would strain existing resources due to the world's highest population density (exceeding 5,500 per square kilometer) with a high number of Palestinians being registered as refugees, further intensifying resource pressures (Statista, 2023).
The primary health care system in the Gaza Strip covered approximately 78% of Palestinians, with significant contributions from the Government Health Insurance and UNRWA, constituting over 90% of health coverage. Government health insurance encompassed services such as maternal and child health, secondary and tertiary care, and essential prescription medicines, with 45.5% of health financing coming from out-of-pocket payments (Alkhaldi et al., 2021).
UNRWA operated 65 health centers but faced a severe financial crisis in 2018, and a withdrawal of funding during this ongoing war - jeopardizing essential primary healthcare services (UNRWA, 2019 & Alkhaldi et al., 2021). The Ministry of Health (MOH) managed about one-third of the 160 primary health clinics, and bed capacity was distributed with the MOH providing 73%, non-state actors 22%, and the Military Medical Services 6%. Human resources constituted 49% of the total MOH expenditure, with ongoing workforce scarcity and wage reduction challenges (UNRWA, 2019 & Alkhaldi et al., 2021). Despite challenges, the vaccination program has achieved over 95% coverage for children due to international support (Palestinian Health Information Center, 2018 & Alkhaldi et al., 2021). The Healthcare system in Gaza was found to be quite ‘resilient’ according to management staff at the main healthcare organizations. Over 75% of respondents found the healthcare system to be adaptive, integrated, characterized by diversity, and self-regulated. International agencies contributed to that resilience mostly through mobilizing resources in the immediate response to emergencies (Al Moghany, 2020).
Despite the dedication of organizations like the MOH, UNRWA, WHO, UNICEF, UNFPA, and NGOs operating an extensive network of primary healthcare centers, coordination and resource allocation remain problematic, and healthcare inequalities still exist (Alkhaldi et al., 2021). These inequalities are shaped by social, economic and political determinants of health (Alkhalidi et al., 2021). As one example, a recent analysis indicated that the unemployment rate in Gaza was 52% in 2018, 2.5 times higher than the rate in the West Bank and almost 5 times higher than the unemployment rates in Israel. Since the blockade in 2007, Gaza’s GDP has averaged 1% growth per year, as opposed to 6% in the West Bank. Similar challenges face education, housing, agriculture, water and sanitation systems. An analysis of health disparities between Israel and the Occupied Palestinian Territories - oPt (West Bank and Gaza Strip) (Rosenthal, 2021), found a nine-year higher life expectancy in 2016 for people in Israel (82.4) than the oPt (73.5), Infant mortality rates in 2017 were at 2.9/1000 in Israel, and 17.9/1000 in the oPt. Statistically significant differences in age-standardized mortality rates were found between Israel and oPt for 14 out of the 20 leading causes of death in the oPt. For example, ischemic heart disease mortality rates in Israel were 47.7/100,000 as compared to 153/100,000 in the oPt (a ratio of 3.2); about half of those deaths (53.2%) in Israel were attributed to dietary factors, as compared to almost three fourths (72%) in the oPt. Mortality rates from neonatal disorders were 2.9/100,000 in Israel and 15.8/100,000 in the oPt (a ratio of 5.5). Confirming the impact of the social, economic, and political determinants of health in the oPt, very few of the differences in mortality could be attributed to differences in behaviors (Rosenthal, 2021).
Despite these disparities, health related indicators have improved in Gaza over time. Infant mortality (20 per 1,000 live births in 2019) had dipped below the global average. The under-five mortality rate had also significantly improved (12.1 per 1,000 live births in 2019) mainly due to implementing programs supporting maternal and child health services (Van den Berg et al., 2018 & Alkhaldi et al., 2021). However, significant challenges remain. Maternal mortality (27 deaths per 100,000 live births) remained alarmingly high in the Gaza Strip, exceeding both global and regional figures, highlighting persistent struggles (Alkhaldi et al., 2021). Armed conflict has been linked to higher rates of maternal mortality (Jawad et al., 2021). Also, in Gaza, even before the recent crisis, nearly 1 in 10 children under five suffered from stunted growth due to chronic malnutrition. Despite this, wasting and underweight rates were low. However, a worrying 77% of the population relied on external food assistance, and only half of the children had enough variety in their diets. “Nutrition has been weaponized as a result of the siege; Israel severely restrains food imports and only allows a “minimal subsistence basket”” (Farhat et al., 2023, p.3). This lack of dietary diversity was reflected in high rates of anemia and obesity, alongside infant feeding practices like low rates of exclusive breastfeeding and high formula use. While chronic malnutrition wasn't widespread, these underlying vulnerabilities point to a population already facing food insecurity and potential health risks (Checchi et al., 2023). Relatedly, NCDs remain highly prevalent among Palestinians in the Gaza strip. Two thirds of adults’ deaths are attributable to NCDs. Access to affordable medications and specialized care for non-communicable diseases has been restricted by the blockade (Alkhaldi et al., 2021).
Additionally, research has shown that mental distress represents one of the most significant health challenges faced by Palestinians, especially in the Gaza Strip, mainly related to the Israeli Occupation Forces. Mental health cannot be separated from the social, economic, and political environments, and Western idioms of distress may not be ideal in all wars (Hindi, 2018; Giacaman, 2017; Tawil, 2013; Wispelwey & Jamei, 2020). Mental health services are hampered by the stigma surrounding mental illness and insufficient mental health providers but the nature of mental health services needs to be interrogated in these settings of war and structural oppression, and in collectivist communities. Care and healing are community events, not individual events. “Family- and community-based psychosocial and psychological programs are aimed at reconnecting individuals’ systems of meanings, and collective psychological and emotional narrative activities that are interrupted and fragmented by extreme traumatic experiences” (Diab et al., 2018, p.321). The Gaza Community Mental Health Program uses a socio-ecological approach to the provision of mental health services addressing primary, secondary, and tertiary prevention through tailored programs; and infuses its programs with a human rights approach. When human rights and social justice are eroded as in the Israeli wars on Gaza, the 16-year blockade, and ongoing settler colonialism, a focus on restoring dignity and security is critical even for secondary and tertiary prevention programs (Diab et al., 2018). Strong community-based psychosocial care is necessary and has supported mental healing in Gaza for decades, with the acknowledgment that healing occurs in the community and centers community voices (Rabaia et al., 2014; Diab et al., 2018; Diab et al., 2023).
While Gaza's public health system had made progress, significant challenges persist due to the ongoing Israeli blockade and constant military attacks, population growth, and limited resources. With the devastating impact of the war, priorities for rebuilding health in Gaza should include addressing these gaps, strengthening the health system, focusing on the broader social, economic, and political determinants of health, and improving resource allocation as a prerequisite for ensuring equitable quality health for all residents.
- Rebuilding Health in Gaza: Is a medical infrastructure enough?
We argue in the above sections that the Public Health System in Gaza has demonstrated a lot of flexibility and adaptability to the unbearable living conditions and high health needs during the war, hence contributing to the resistance and soumoud of the population. No doubt, however, that the public health system has suffered tremendously like all other sectors in the Strip. It is reported that currently, 46 out of 72 primary healthcare facilities (64%) in Gaza as a whole are not operational, but it is worse in Gaza City (74%) and northern Gaza (92%) (WHO(b), 2023). This means that people’s access to primary health care, especially for women, children, and persons with NCDs on medications, has been severely disrupted and that preventive programs such as vaccination, surveillance, maternal and reproductive health, NCD screening and management, and others have been frozen.
An immediate and lasting ceasefire and stopping the war is the most effective strategy to restore short-term health and wellbeing in Gaza, and an end to the occupation is necessary for long-term health and wellbeing. It is hard to anticipate needs while the war is ongoing. This war has been dynamic and ruthless and has thus far displaced a staggering 1.9 million persons (close to 80% of the total population), most of them more than once (NRC, 2023). Hence, we urge the conference and all those concerned with health in Gaza to focus on the rebuilding of the Public Health System as a priority; such a plan is best conceived and implemented after surveying the distribution and skills of the remaining public health workers, mapping where people are living and under what circumstances, and assessing the health needs of the population (first using a quick needs assessment approach and later a well-executed survey).
The re-building of the medical infrastructure is no doubt critical and necessary, but it is not sufficient. Only 10%-20% of health outcomes are related to health care. The remaining 80-90% require a focus on social, economic, environmental, educational, and political determinants of health (Magnan, 2017). If the public health system in Gaza is weak or deficient, the secondary and tertiary health systems will be overwhelmed and may succumb to the rising health needs of the population. Medical infrastructures are very expensive endeavors and will take time to rebuild, and it will be both a big financial and human resource loss if it is the only option for healthcare. Although such a gap may be filled by field hospitals, it still cannot address the basic health needs of people in all age categories. Furthermore, besides health needs, the health system has to work closely with other sectors whose conditions will impact people’s health and wellbeing. These conditions include social conditions (no schools or education, not enough food, and nutrition, loss of loved ones, broken social networks), environmental conditions (limited access to water, poor quality of water, poor sanitation and hygiene, overcrowding), economic conditions (destroyed economic sectors, limited jobs, increase in child labor), and political conditions (security, neighborhood safety). A public health approach will situate the restoration of the public health system within the overall effort to rebuild and restore other sectors.
On a practical level, people in need of healthcare may not be able to access medical facilities, hence it is critical to be proactive and reach out to people where they live, work, and play, especially children, pregnant women and women with children, older adults, and injured and disabled persons. The Gaza Strip already has an infrastructure of existing community healthcare workers; they should be mobilized and prioritized as the main healthcare workforce over international healthcare workers entering the Gaza Strip; and more should be trained (UNRWA, 2024). Nurses, midwives, paramedics, youth and young adults, and women and men trusted in their communities can be trained to serve in such a capacity, assessing living and health and social needs, providing basic health care, and facilitating people’s access to social and health services. This community health workforce would become the front liners who can serve as data collectors for needs assessment and population surveys, as well as a voice for the general population.
In short, the social, economic, environmental, and health needs of the population of Gaza will be astronomical, and rebuilding efforts will be slow and expensive. Adopting a public health approach that looks at these needs comprehensively and interconnectedly should be an absolute must, and not a luxury or an afterthought.
- The values and elements of Public Health as an approach to rebuild health in Gaza
Once the importance of a broad public health approach is recognized, the work turns to ensuring that the values and elements of this approach are implemented. The core values of public health are health equity and social justice. Health equity entails ensuring the opportunity/capacity for everyone to achieve optimal wellbeing (CDC, n.d.). This is impossible without social justice – the removal of all social, economic, educational, commercial, and political obstacles to wellbeing, and the realization of community and individual rights. There is no health and no healing without social justice (Khosla & Venkatapuram, 2023; Galea, 2018). Beyond the cease fire required for health and wellbeing, the end of occupation is necessary.
Public health principles guide the action needed to achieve health equity and social justice. These principles include:
- The centering of community voices and narratives – a people first – or ‘nothing about me without me’ participatory approach.
- A strength and assets-based, dignity-focused, protective factors approach (rather than a purely deficit problem-focused risk factor approach) that uplifts ’soumoud’ (steadfasteness), protective factors, and local solutions.
- A comprehensive holistic strategy for assessing health and wellbeing, rather than a siloed assessment that lacks linkages between health-related conditions and determinants. Syndemics - recognized as the interaction of multiple vulnerabilities and diseases and their interconnectedness with the social, environmental or economic factors that promote such interaction and negatively impact health - are now widely acknowledged to be contributing to increasingly dangerous and interacting risk factor and disease trajectories (Singer et al., 2017). Medical care alone will only fail to address actual needs and determinants affecting people’s health and well-being.
- A transdisciplinary multisectoral partnership that brings together and builds on expertise across disciplines and sectors, and partners - local, regional, and international; governmental and non-governmental; formal and informal; community leaders and disciplinary experts. Health is not possible without this partnership. The goal is strengthening public institutions that serve everyone, rather than private ones.
- An outward-facing rather than inward-looking process – meeting people where they are rather than having them come to where we are.
- A story-telling and numbers-focused initiative using qualitative and quantitative methods. Numbers without stories can only lead to the understanding of a fraction of the issue.
- A strategic focus on current humanitarian needs and immediate and future developmental needs. A focus solely on current urgent needs can uplift savior tendencies and create dependence, contrary to the values of health equity and social justice.
- Public health aspects of the immediate and intermediate response: What are the priority areas of focus?
Gaza is now in urgent need of all the necessities of life that were destroyed by the war. The top priority, which we consider as a precondition for implementing effective interventions to save lives and promote health, is stopping the war on the Gaza Strip immediately, withdrawing the occupation army, lifting the siege, and allowing freedom of movement. Due to the systematic destruction of the livelihood components, including the economic, agricultural, nutritional, municipal, industrial, educational, social, and health infrastructure, it is very challenging to prioritize the survival needs of the population in Gaza. However, some priority areas are apparent.
There is a severe water shortage; for example, in North Gaza, there is no access to clean water, while in Southern Gaza, children are getting between 1.5 and 2 liters of water per day, which is less than the minimum quantity of 3 liters required for mere survival. “According to humanitarian standards, the minimum amount of water needed in an emergency is 15 liters, which includes water for drinking, washing, and cooking” (OCHA, 2024). Sanitation is also a big problem; poor sanitation due to infrastructure destruction and the lack of fuel for water pumps and wastewater treatment makes this mission impossible. The same applies to solid waste management. Poor sanitation has detrimental health effects that were observed mainly through the increase in hepatitis A cases reported by the WHO, which is usually transmitted by contaminated water. Infectious diseases, especially diarrheal and upper respiratory infections, are spreading rapidly. As of January 11, 2024, more than 150 thousand cases of diarrhea were reported; of those, more than 80 thousand cases were among children under five years, a 23-fold increase from the 2022 baseline (WHO, 2024).
For chronic diseases, more than 350 thousand cases exist with no or minimal access to medicines and medical services, including 225 thousand people with high blood pressure, 71 thousand with diabetes, 45 thousand with cardiovascular diseases, 2000 cases of cancer diagnosed per year, and 1100 kidney dialysis patients. Food insecurity affects the 2.2 million population of Gaza, including children and pregnant women. Nutrition partners and organizations can meet only a quarter of the nutritional requirements of malnourished children and vulnerable mothers for the coming two months if no immediate and comprehensive action is taken (WHO, 2024; OCHA, 2024).
The war-caused physical and mental injuries should constitute a top priority in any response plan and efforts for rebuilding health. The huge number of children with disabilities will pose a significant burden on the future health and social system of Gaza. Alleviating this burden and accommodating this increasing need for specialized care requires extraordinary measures for affected children and their families in terms of securing treatments, psychosocial support, and re-integration in the education and employment sectors.
The unbearable emotional and mental toll of what the population of Gaza is witnessing is yet to be manifested. The unprecedented loss of lives and livelihoods, destruction of homes, deprivation of basic needs, and exacerbated vulnerabilities will impact the mental health and wellbeing of the population for generations to come. The current situation calls for a consolidated effort by all concerned stakeholders contributing to rebuilding health in Gaza to ensure that mental health is not overlooked and that all its aspects are covered through a comprehensive strategy that caters to both short-term and long-term plans for mental health care and support, away from the typical western PTSD, focusing on more contextually-relevant community-based approaches.
Narratives about Palestine emphasize resilience as part of the discourse on mental health. Yet, the resilience that is spoken about is not the Western concept. More recent writings have emphasized resilience as a context specific concept that comes from a shared experience of violence/oppression (Marie et al., 2018) that allows the “normalizing of the abnormal” (Nguyen-Gillham et al., 2008). In the Palestinian context, it is a collective concept and is described as “oscillat(ing) on a continuum of ease–disease back and forth daily depending on the degree, severity and chronicity of violation and capacity to endure and resist.” (Giacaman, 2019, p.e370). Resilience is thus linked to agency, to a collective experience of violence and collective healing, to connection to the land, and to the collective moral imperative of resisting an occupier (Giacaman, 2019). A core construct of resilience in the Palestinian context is the concept of Soumoud which means steadfastness and rootedness to land (Nguyen-Gillham et al., 2008; Hammad & Tribe, 2021). The discourse on resiliency has also made clear that any discussion of resilience without the demand for social justice and liberation only furthers colonialism, violence, and oppression (Giacaman, 2019; van de Pas et al., 2027).
Gaza has experienced and qualified health human resources, including community health workers; it is essential to capitalize on that and move resources to support them in implementing all public health functions to sustain and build a resilient health system for now and in the future. It is essential to work with the health providers in Gaza to conduct a quick needs assessment, apply pressure to allow the entry of all needed supplies, equipment, and volunteer specialized health human resources, and resume training of public health human resources in Gaza, including local volunteers, to adapt to the current situation and needs.
In the face of years of siege and relentless attacks, economic challenges, and political complexities, the people of Gaza have shown extraordinary resilience and adaptability. This resilience is deeply rooted in the strong community networks within Gaza as in Palestine more broadly, where families and neighborhoods have forged powerful bonds of mutual support and cooperation. However, while Soumoud (steadfastness) prevails, it is imperative to confront the root causes that required Soumoud, and advocate for sustainable solutions addressing those root causes.
In conclusion, we argue that a public health approach to rebuilding health in Gaza should not be negotiable. The international community must provide urgent and unequivocal support to the health system in Gaza. Moreover, the Israeli attacks and siege on Gaza, which have severely limited access to essential healthcare services, must end. This has compounded the strain on resources, further exacerbating the public health crisis. Therefore, it is a moral imperative to increase international support and intervention that respond to locally-identified community-based solutions, for a comprehensive public health system that addresses the physical, mental, environmental, social and political aspects of health. The international community must take decisive action to provide sustained aid and respond to both the immediate needs and the long-term consequences of the attacks on Gaza's public health system. This calls for consolidated and coordinated efforts from all partners, whether internal or external, across various sectors. It is our collective responsibility towards humanity to strive towards a future where the people of Gaza, and in Palestine more broadly, can live in peace, dignity, and with self-determination.
References:
AlKhaldi, M., Abuzerr, S., Obaid, H. A., Alnajjar, G., Alkhaldi, A., & Alkaiyat, A. (2020). Social Determinants of Health in Fragile and Conflict Zones Before and During Coronavirus Pandemic: the Focus on the Gaza Strip. Handbook of Healthcare in the Arab World. Springer International Publishing.
Al Moghany, R. (2020). Contribution of the International Agencies to Supporting the Resilience of Health Care System in the Gaza Strip. Dissertation. [Master’s thesis, Al Quds University]. Al-Quds University.
Checchi, F., Jamaluddine, Z. Campbell, O. (2023). War in the Gaza Strip: Public Health Situation Analysis. Health in Humanitarian Crises Centre London School of Hygiene and Tropical Medicine.
Cheng, P., Yin, P., Ning, P., Wang, L., Cheng, X., Liu, Y., Schwebel, D. C., Liu, J., Qi, J., Hu, G., & Zhou, M. (2017). Trends in traumatic brain injury mortality in china, 2006–2013: A population-based longitudinal study. PLoS Medicine, 14(7), e1002332.
Centers for Disease Control and Prevention. (n.d.). What is Health Equity?
DeAngelis, T. (2017, November). Trends report: Targeting social factors that undermine health. American Psychological Association.
Defense Health Hub (n.d.). What is physical health? Defense Hub.
Diab, M., Veronese, G., Jamei, Y. A., Hamam, R., Saleh, S., & Kagee, A. (2018). Community work in the ongoing crisis context of gaza: Integrating a public health and human rights approach. Australian and New Zealand Journal of Family Therapy, 39(3), 320-330.
Diab, M., Veronese, G., Abu Jamei, Y., Hamam, R., Saleh, S., Zeyada, H., & Kagee, A. (2023). Psychosocial concerns in a context of prolonged political oppression: Gaza mental health providers’ perceptions. Transcultural Psychiatry, 60(3), 577-590.
Euro-Med Human Rights Monitor. (2024, February 23). Statistics on the Israeli attack on the Gaza Strip (07 October - 23 February 2024).
Farhat, T., Ibrahim, S., Abdul-Sater, Z., & Abu-Sittah, G. (2023). Responding to the humanitarian crisis in gaza: Damned if you do… damned if you don’t. Annals of Global Health, 89(1), 53-53.
Galea, S. (2018, May 11). Why there can be no health without social justice. Boston University School of Public Health.
Gaza Strip - Statistics and Facts. (2023). Statista.
Giacaman, R. (2017). Social suffering, the painful wounds inside. American Journal of Public Health, 107(3), 357-357.
Giacaman, R. (2020). Reflections on the meaning of ‘resilience’in the Palestinian context. Journal of Public Health, 42(3), e369-e400. https://doi.org/10.1093/pubmed/fdz118
Hindi, E. (2018). A Revised Biosocial Analysis to Social Suffering: Reframing a Paradigm on Mental Health for Palestinians Living Under Trauma (Publication No. 28275661) [Master’s thesis, Harvard University]. ProQuest Dissertations Publishing.
Holt-Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS medicine, 7(7), e1000316. https://doi.org/10.1371/journal.pmed.1000316
International Committee of the Red Cross. (2023, November 02). The protection of hospitals during armed conflicts: What the law says. https://www.icrc.org/en/document/protection-hospitals-during-armed-conflicts-what-law-says#:~:text=According%20to%20international%20humanitarian%20law,staff%20and%20means%20of%20transport
International Humanitarian Law Databases. (n.d.). Rule 53. Starvation as a method of warfare. International Committee of the Red Cross. https://ihl-databases.icrc.org/en/customary-ihl/v1/rule53
Jawad, M., Hone, T., Vamos, E. P., Cetorelli, V., & Millett, C. (2021). Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000–2019. PLoS Medicine, 18(9), e1003810. https://doi.org/10.1371/journal.pmed.1003810
Khosla, R., & Venkatapuram, S. (2023). What is a justice-oriented approach to global health?. BMJ global health, 8(3), e012155. https://doi.org/10.1136/bmjgh-2023-012155
Magnan, S. (2017). Social Determinants of Health 101 for Health Care: Five Plus Five. (Discussion Paper). National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201710c
Medecins Sans Frontieres. (2023, October). Palestine: Healthcare workers in Gaza confront stress on the frontlines.
Norwegian Refugee Council. (2023, December 26). Gaza: Forced and protracted displacement of Palestinians would constitute a serious breach of international law and an atrocity crime.
Nguyen-Gillham, V., Giacaman, R., Naser, G., & Boyce, W. (2008). Normalising the abnormal: Palestinian youth and the contradictions of resilience in protracted conflict. Health & Social Care in the Community, 16(3), 291-298.
Palestine Chronicle Staff. (2023, November 14). Israeli Attacks on Gaza’s Healthcare System Should Be Investigated – Human Rights Watch.
Palestinian Health Information Center. (2019). Health Annual Report Palestine 2018. State of Palestine Ministry of Health.
Rabaia, Y., Saleh, M. F., & Giacaman, R. (2014). Sick or sad? Supporting Palestinian children living in conditions of chronic political violence. Children & Society, 28(3), 172-181.
Reuters. (2023, October 7). Timeline of conflict between Israel and Palestinians in Gaza.
Rosenthal, F. S. (2021). A comparison of health indicators and social determinants of health between israel and the occupied palestinian territories. Global Public Health, 16(3), 431-447.
Singer, M., Bulled, N., Ostrach, B., & Mendenhall, E. (2017). Syndemics and the biosocial conception of health. Lancet (London, England), 389(10072), 941–950. https://doi.org/10.1016/S0140-6736(17)30003-X
Substance Abuse and Mental Health Services Administration. (2023, April 24). What is Mental Health?.
Tawil, S. (2013). No end in sight: Moving towards a social justice framework for mental health in continuous conflict settings. Intervention, 11 (1), 24-36.
United Nations International Children's Emergency Fund. (2019, December 26). Gaza clinics on front line in fight to prevent health system collapse.
United Nations (a). (2023, December 8). Stories of courage and dedication: Humanitarians on Gaza’s front line.
United Nations. (2024, January 5). Nearly 600 attacks on healthcare in Gaza and West Bank since war began: WHO.
United Nations Relief and Works Agency for Palestine Refugees in the Near East. (2019, January 29). Occupied Palestinian Territory Emergency Appeal 2019. UNRWA.
United Nations Relief and Works Agency for Palestine Refugees in the Near East. (2024, February 13). UNRWA at the frontlines: managing health care in Gaza during catastrophe. UNRWA.
United Nations (b). (2023, November 13). UN honours 101 staff killed in Gaza conflict.
United Nations Office for the Coordination of Humanitarian Affairs. (2020, October). Deterioration in the mental health situation in the Gaza Strip.
United Nations Office for the Coordination of Humanitarian Affairs. (2023, October 24). Hostilities in the Gaza Strip and Israel | Flash Update #18.
Van Den Berg, Maartje M., Khader, A., Hababeh, M., Zeidan, W., Pivetta, S., El-Kader, M. A., Al-Jadba, G., & Seita, A. (2018). Stalled decline in infant mortality among palestine refugees in the gaza strip since 2006. PloS One, 13(6), e0197314-e0197314.
Van de Pas, R., Ashour, M., Kapilashrami, A., & Fustukian, S. (2017). Interrogating resilience in health systems development. Health policy and Planning, 32(suppl_3), iii88–iii90.
Wispelwey, B., & Jamei, Y. A. (2020). The great march of return: Lessons from Gaza on mass resistance and mental health. Health and Human Rights, 22(1), 179-186.
World Health Organization Health Cluster. (2024). occupied Palestinian territory.
World Health Organization (a). (2023, October 17). Health Promotion.
World Health Organization (b). (2023, October 26). WHO Operational Response Plan: occupied Palestinian territory.
World Health Organization. (1946). Constitution of the World Health Organization.
World Health Organization. (2024). Surveillance System for Attacks on Health Care (SSA).
World Health Organization. (2018, May 18). Gaza: frontline health care innovation saves lives and reduces hospital load.
Zerrouky, M. (2023, October 13). Le Monde. In Gaza, Palestinian journalists are on the front line.