By Yara M. Asi
For the wounded, injured and sick in Gaza, there is seemingly no escape. On Oct. 17, 2023, news broke that at least 500 patients, staff and people seeking shelter from Israeli bombs had been killed in an explosion at a hospital, according to health authorities in the Hamas-run enclave.
It amounts to a devastating loss of life during a campaign of bombing that has not spared the frail or sick. Just days earlier, the World Health Organization said in a stark assessment that an order to evacuate from hospital beds and head south amounts to a “death sentence.”
By that time, four hospitals had already ceased functioning in Gaza’s north because of damage from Israeli bombs.
Beyond the sheer immediate devastation of the current conflict – in which thousands of Israelis and Palestinians have been killed – there will be significant and undoubtedly long-lasting implications for the Gaza Strip’s health system.
As a Palestinian expert in global health who has worked with medical professionals from Gaza, I know that even before this latest escalation of violence, health services in Gaza were in a poor shape. Insufficiently and poorly resourced for decades, doctors and hospitals also had to contend with the devastating effects of a 16-year blockade imposed by Israel, in part with coordination with Egypt.
A system completely overwhelmed
The immediate concern in Gaza is for those seeking assistance due to the bombing campaign that Israel ordered after an attack on its people by Hamas fighters. An expected ground offensive will only further risk more civilian casualties.
Hospitals in Gaza are completely overwhelmed. They are seeing around 1,000 new patients per day, in a health system with only 2,500 hospital beds for a population of over 2 million people. It has forced hospitals to tend to patients in corridors and nearby streets. People maimed in the bombing are being treated for horrific injuries without basics such as gauze dressings, antiseptic, IV bags and painkillers. Those experiencing traumatic injuries are unable to receive sufficient care, increasing rates of infection and amputation.
Abed Zagout/Anadolu via Getty Images
And things may soon get worse. According to the United Nations’ Office for the Coordination of Humanitarian Affairs, Gaza’s hospitals have been forced to work without electricity, using fuel to run generators to ensure life-saving equipment remains functioning. The U.N. estimates this fuel will run out any day due to a complete siege placed on Gaza by Israel.
Such conditions have led to concerns that alongside the massive number of bombing victims, Gaza health services will soon have to contend with the outbreak of disease. Patients with immediate health needs, like dialysis or chemotherapy, are among those being ordered to leave and head for greater safety in Gaza’s south, although evacuation routes have also been bombed.
A century of underfunding
The current devastation to Gaza’s health system is obvious. But Gaza’s health care system was already under stress before the latest bombardment. In fact, policies that stretch back decades have left it unable to meet even the basic health needs of Gaza’s residents, let alone respond to the ongoing humanitarian catastrophe.
In just over a century, the health system in Gaza has been administered by six authorities: the Ottomans until the end of World War I, the British during the mandate period from 1917 to 1947, Egypt from 1949 to 1967, Israel under occupation starting in 1967, and then a Ministry of Health led first by the Palestinian Authority from 1995-2006 and since then by Hamas.
What each have had in common is that, from my perspective as a global health expert, they invested little in Palestinian health. For periods of the 20th century, the health priorities of successive governing bodies appeared focused more on reducing the spread of communicable disease to protect foreigners interacting with the native Palestinian population.
There was seemingly far less attention paid to building health infrastructure, adequately training health personnel, promoting preventive care and other long-term initiatives that make up a sustainable health system.
Under Israeli occupation from 1967, several Palestinian hospitals were turned into detention centers or military offices, while others were closed, and new ones were prohibited from opening. Palestinian physicians working in the occupied territories earned one-third the salary of their Israeli counterparts.
As a result of this neglect, health indicators throughout what are now called the occupied territories – the West Bank and Gaza Strip – have been poor.
Maternal and infant mortality – typical indicators of health system functioning – tends to be high. For example, in the mid-1980s, infant mortality was over 30 per 1,000 live births for Palestinians, compared with just under 10 per 1,000 among the Jewish population of Israel. And infant mortality has remained stubbornly high in Gaza.
Meanwhile, a lack of a reliable drinkable water infrastructure and overall unsanitary conditions resulted in the spread of parasitic and other infectious diseases, like rotavirus, cholera and salmonella – which remain leading causes of death in Gaza’s children.
Dying before they can leave
Most residents of Gaza fled there in 1948 after being displaced from their homes in what became the state of Israel. They were classified as refugees, many receiving limited services from the United Nations Relief and Works Agency for Palestine Refugees in the Near East that was established in 1949.
Since then, chronic underfunding of public hospitals has meant that Palestinians in Gaza have remained reliant on outside money and nongovernmental organizations for essential health services. This started a trend of humanitarian dependence that continues to this day, with many of Gaza’s health facilities funded by the United Nations, humanitarian agencies like Doctors Without Borders and religious organizations.
During the passage of the Oslo Accords in the mid-1990s, the Palestinian Authority was established to administer services in the occupied territories. The accords called for health responsibilities to be transferred to the newly formed Palestinian Ministry of Health as preparation for a sovereign Palestinian state, which the accords called for within a five-year period.
The Palestinian Authority received a significant influx of humanitarian aid as it took on civil responsibilities, including health. As a result, health indicators for Palestinians, including life expectancy and immunization rates, started to improve in the late 1990s.
But as it became increasingly clear that the overarching goal of the Oslo Accords for Palestinians – statehood – would not materialize, disillusion with the Palestinian Authority led to victory for Hamas in 2006 elections held in Gaza. Since then, Hamas has been considered the de facto governing body in Gaza, while the Palestinian Authority operates in the West Bank.
The rise of Hamas, which the U.S., Israel and others designate as a terrorist group, saw Gaza become isolated from the international community. It also coincided with Israel imposing a full land, sea and air blockade of Gaza.
There is no doubt that the blockade has rapidly accelerated the deterioration of the health system in Gaza and directly impacted the mortality rate.
Gazans who need advanced care, whether for cancer or other chronic illnesses, traumatic injuries and other life-threatening ailments, often can only access needed services in Israeli hospitals and require a permit to cross the border from Gaza. Some die before the permit process is complete.
Gaza health services after the siege
This vulnerable health system is now facing unprecedented challenges, staffed by health professionals who have committed to stay with their patients even under hospital evacuation orders and at risk of death.
It is uncertain what the health system of Gaza will look like in the future.
In years past, international aid would help repair and rebuild some, but not all, of the infrastructure damaged in airstrikes, especially schools and hospitals.
But Israeli Prime Minister Benjamin Netanyahu has promised a “long and difficult war.” And with the level of destruction seen in just a few days, it remains unclear just what will be left in the aftermath.
Already at least 28 doctors and other health workers have been killed in Gaza, with ambulances and a number of hospitals rendered useless by the bombs.
Replacing this human capital and vital infrastructure could take years, if not generations – and that is without the limits of a punishing blockade and continued bombardment.
This article was updated on Oct. 17, 2023 to add news of an airstrike on a Gazan hospital.
Yara M. Asi is Assistant Professor of Global Health Management and Informatics at the University of Central Florida.
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Justice says
No one cares about their health care system. No muslim country around them wants to take them in. Israel provides them with food and water and yet they attack them, Allow them to succumb to their own demise
JimboXYZ says
All of this could’ve been avoided, but one side chose to attack the other. Funny (odd) how we went from saving the human race over Covid & circled back to these type of conventional wars. The human race at it’s finest, continuing to disappoint. Devoid of a common external enemy, will always turn on the enemy amongst themselves internally.
Marc Crane says
It seems time the Palestinians stood up for them selves and remove Hamas as their leaders , their world and ours would be a safer place.
DaleL says
They should, but it is very hard for an oppressed people to overthrow a dictatorial authoritarian government. In many cases, due to propaganda, the people do not even realized that they are being oppressed by their rulers. I am confident that the children in the Gaza strip are taught to hate Jews and Israel. Every hardship is blamed on Israel.
History is also full of examples in which the dictator is overthrown and the result is a government just as bad or worse.
Habitat Loss says
Israeli terrorist really showing them how to terror properly.
ellen says
Gaza won’t become safe until some one TAKES OUT HAMAS, I stand with Israel,
PeaceBro says
I’ll be waiting on a correction as we know know for certain that Hamas sent a rocket from the cemetery behind the HOSPITAL and in a residential area which mis-fired and fell on the hospital killing all those Gazan People that Israel is trying to protect as they avenge the raid and massacre of hundred of Women, Men, children and BABIES. You can watch it yourself.
DaleL says
Prior to 1948, there was a sizable Jewish population in Gaza and other cities in Palestine. In 1947, one third of the population of Palestine was Jewish. A little less than ten percent were Christian. The United Nations created a partition plan for Palestine in 1947. According to the plan, Jews and Arabs living in the Jewish state would become citizens of the Jewish state and Jews and Arabs living in the Arab state would become citizens of the Arab state. The United Nations resolution on partition was greeted with widespread outrage in the Arab world. In Palestine, violence erupted, with of reprisals and counter-reprisals.
On May 14, 1948, after months of increasing violence between Arabs and Jews, Israel declared independence. The very next day, military forces from Egypt, Transjordan, Syria, Lebanon, and Iraq entered Palestine to destroy the Jewish state. The invading armies immediately attacked Israeli forces and Jewish settlements. It was not until 1949 that an armistice agreement was reached.
Arab League’s Secretary-General Azzam Pasha, before the armies marched, is reported to have said: “We will sweep them into the sea.” “…this will be a war of extermination and a momentous massacre which will be spoken of like the Mongolian massacres and the Crusades.”
The people of Gaza are in a terrible situation. Hamas controls Gaza and is using the civilians as human shields. Hamas is holding about 200 Israelis as prisoners and threatening to murder them. Pressuring Israel and Egypt to relieve the suffering in Gaza is misguided. It is Hamas and its allies which are the problem. Any solution must include the defeat and removal of Hamas.
Foresee says
The silence is deafening. Where is the overwhelming sense of outrage in the international community over what is happening in Israel vs. Palestine? There is none, except for the U.S. That is because, regardless of circumstances, human nature abhors a bully. The world sees the overwhelming might of the U.S. aiding Israel while Palestinians flee with all their possessions loaded on donkey carts, Palestinians using slings to throw stones at Israeli soldiers. This carnage could be stopped if only the U.S. told Israel in no uncertain terms that they must immediately agree to a fair 2 state solution; otherwise we would stop sending weapons to Israel, and cut off their foreign aid. According to the International Monetary Fund’s World Economic Outlook database, Israel’s per capita income has multiplied by more than nine times to reach $58,273, which is the second highest in the Middle East after Qatar ($83,890). In fact, in 2023 prices, Israel’s per capita income is higher than that of many ‘developed’ countries such as the United Kingdom ($46,370), Germany ($53,800), France ($45,190) and Saudi Arabia ($29,920). According to US Census, per capita income for Flagler County (2017-2021) is $35,500.
The tail is wagging the dog. Our greater national interest lies in Ukraine.
hippy says
How many hospitals did the elected Hamas government build since it has been in power? How many clinics did the Hamas government put in place in Gaza since they were elected. . How many billions have the Hamas supporters such as Iran provided to build hospitals and clinics for the Palestinians in Gaza? Hamas new exactly what would happen and that thousands of innocent Palestinians would die when they slaughtered innocent people in Israel. They want to play the propaganda war and now they try to play the propaganda war with Palestinians they killed with their own rockets. Hamas cares nothing about the Palestinians. They only want to kill Jews and use the people living in Gaza as fodder for a propaganda war.
ASF says
The Palestinians have received more “refugee aid” and other forms of ongoing and open-ended humanitarian assistance than any iother naiton or group in history. Their “siege” is a result of their own terrorism, rocket fire and recent war crimes. Even other neighboring Arab countries don’t want to have much, if anything, to do with them.
I would say that the Palestinians need to be more accountable for their own sins, not less. Israel is not responsible for their vast corruption and their abysmal internal governance. As long as the Palestinians continue to priortize their Jew Hate over everything else, Israel can only defend itself against the deadly side effects of those social/cultural and political ills.
FlaglerLive says
The Washington Post in 2019 put to rest that old misleading myth and its attempted “humanitarian” caveat made by the commenter above, giving the claim three Pinoccchios–i.e. mostly false. The whole piece is worth a read, but here’s the sum-up: “The State Department’s foreign aid database shows that U.S. aid to Israel totaled $228 billion in constant 2017 dollars between 1951 and 2017. U.S. assistance to Israel was especially significant in some years, topping $10 billion in 1974 and $13 billion in 1979. These figures were so unexpectedly high that we confirmed them with the State Department to make sure the calculations were correct. Put another way, Israel has been getting an average of $3.5 billion a year for 66 years — just from the United States — while the Palestinians have received about $1.7 billion a year from international donors. Even if the Palestinian figure is undercounted somewhat — such as some UNWRA funding not recorded in these statistics — there’s little chance it can match the aid figure for Israel. If we count just from the signing of the 1993 Oslo accords, Israel still has received $95 billion in constant dollars, more than twice as much aid as the Palestinians in that time period.”
Notably, “Every dollar Israel receives for its military means one more dollar it can spend on internal development. So ignoring U.S. military aid to Israel provides an incomplete picture.”
ASF says
Unfortunately for your argument, Biden just pledged yet another 100 million in US tax payer $$, despite the fact that Israeli Americans are sitll being held hostage by Hamas (the hostage count is now at 230 people)–this, despite the passage of The Taylor Force Act by Congress which the Biden Administration has been manuevering around by funding the Palestinians through UNWRA in ever increasing amounts.
UNWRA–which services ONLY the Palestinians–and which receives more $$ than the ONE other UN refugee agency that serivces the needs of ALL other groups of refugees worldwide–was never meant ot become a permanent fixture of the UNited Nations. But, here ww are. Even UNWRA sent out four separate Tweets less than four days ago, suggesting that Hamas Militants were commandeering aid trcks and supplies foir the Gazan Evacuees. Then, they suspiciously deleted the Tweets, without any further explanation
Nothing like real life evidence (that exists in the present day as well as historically) to defeat rhetorical word play.
Pierre Tristam says
$100 million in humanitarian aid for Gaza; $74 billion in military and other aid to Israel and Ukraine. The ratio seems to favor Israel, slightly.
FlalgerNative says
@Pierre – I’ve conducted thorough research, but unfortunately, I couldn’t find specific information on the exact amounts of humanitarian aid provided by Iran to Gaza, or by Egypt and other neighboring countries of Israel to Gaza. However, it is known that various countries and organizations have contributed humanitarian aid to Gaza over the years to support the population in need. Could you also include how much military aid other countries give to the government of Gaza, Hamas. Then include the military aid given to Hezbollah, Palestinian, Islamic Jihad, Al-Qassam Brigades, Al-Aqsa Martyr’s, Popular front for the liberation of Palestine, Al-Qaeda. They are all getting aid from someone with big bank accounts to get the money to try to wipe Israel off the map. to Do you have that information?
Pierre Tristam says
I’m sure you’ll find your own answers to your amazingly disinterested and objective questions.
ASF says
Now that it has become increasingly clear that Hamas and/or Islamic JIhad rockets being aimed (badly) at Israel’s civilian centers actually misfired and ended up blasting that hospital in Gaza, the estimated “death toll” has magically decreased from “200-500 people” to “10-50 people.”
What a coincidinky!