Gaza's health care system crippled before — and after

Christopher Mason

doi:10.1503/cmaj.090201

When Israel began its “Operation Cast Lead” military campaign in the Gaza Strip on Dec. 27, 2008, the Gaza health care system was already crippled by underfunding and a border blockade that prevented needed medical supplies and personnel from entering the region.

The health care system soon buckled under the stress of rapidly rising casualties and infrastructure damage; the World Health Organization (WHO) estimates 34 health facilities were damaged or destroyed in the 22-day conflict.

“The system, after 18 months of blockade, was not prepared to implement a well-organized casualty management response,” says Dr. Mahmoud Daher, a technical officer for the WHO, from Gaza. As one indicator, some 25% of drugs categorized as “essential” were out of stock when the fighting began, according to the WHO.

Among the facilities shelled during Israel's Dec. 27, 2008–Jan. 18, 2009, military campaign was the al-Quds Hospital, Gaza's second largest.

During the conflict, accusations flew that the Israeli military severely hindered medical relief missions through missile attacks on or around health facilities, preventing medical personnel from safely getting to work and limiting the movement of ambulances.

The number of casualties is disputed. Israel says 13 of its citizens were killed, including 4 civilians. The Palestinian Ministry of Health claims that 1300 Palestinians died, including 910 civilians. The Israelis claim those tallies are more like 1100 and 250, respectively. An estimated 16 medical personnel were killed on duty and 22 were injured.

Also disputed is exactly who bombed the headquarters of the United Nations (UN) Relief and Works Agency on Jan. 15, killing 3 and destroying tonnes of food. Yet, regardless of who shelled the facility, the upshot was that the UN stopped humanitarian aid on the Gaza strip. Four UN aid workers were killed.

That prompted some human rights organizations to call for war crimes prosecutions against the Israelis, for preventing medical relief personnel from reaching civilian patients. But the Israelis have long maintained that the purpose of their blockade was to prevent materials that could be used to make bombs from entering Gaza.

Palestinians wait to receive humanitarian supplies from the United Nations Relief and Works Agency headquarters at the Shati refugee camp in Gaza. Image by: Reuters/Suhaib Salem

The infrastructure needs are significant. Health facilities have been damaged or destroyed. Medical workers are pushing for water, sanitation and electricity to be quickly restored to prevent further health problems. Some three-quarters of Gaza, one of the most densely-populated areas on the planet, were without electricity during the conflict. Some 500 000 people were without running water and 37% of water wells were not functioning, according to the Disasters Emergency Committee, a coalition of agencies responding to the Gaza crisis, including Oxfam, the British Red Cross and World Vision.

Infrastructure damage amounts to about US$2 billion and will take 3 to 5 years to repair, according to the Palestinian Central Bureau of Statistics.

The UN Development Programme is now preparing a plan for Gaza reconstruction. Meanwhile, many nations have pledged support, including Saudi Arabia, which has already offered US$1 billion toward rebuilding infrastructure, including health facilities.

One challenge is figuring out how to get those building supplies into Gaza. Israel has a long-standing ban on goods entering Gaza that could be used to make bombs — namely pipes and fertilizer. “We're looking to work with the international community to identify the needs on a project-by-project basis so that we know where each piece of piping is going so they can't be taken advantage of to rebuild bunkers and rockets,” says Peter Lerner, spokesperson for the Israeli Defense Forces. “In the past, we were limiting movement of pipes into Gaza because even after being put into the ground they were dug up and used for rockets.”

Aid officials say this will have a serious impact on attempts to get the health care system and important infrastructure rebuilt as quickly as possible.

“Medical supplies can be replaced within 1 month,” says Dr. Wael Qadan, director of health services for the Palestinian Red Crescent Society, which is affiliated with the International Committee of the Red Cross. “But the problem is infrastructure.” The potential impact of the ban on construction materials is “very dangerous.”

Aid workers frustrated

The ban is a convoluted issue, but during the conflict, one thing was definitely clear to aid workers: there are few things more frustrating than being caught on the outside looking in during a humanitarian crisis (page 610). Aid workers had donations and supplies at hand, but Israel stopped them from entering Gaza.

This spelled trouble for Gaza residents who watched as their health care system, already weak from a pre-existing shortage of medicine and equipment, buckled under the pressures of war. It also spells a long and arduous rebuilding period to get health care in Gaza back on track.

The fact that aid workers found themselves on the outside looking in created a “hurry up and wait” scenario whereby emergency response experts and donations flooded the surrounding region, but could not get into Gaza.

“It was a very, very frustrating and emotionally demanding time,” says Dr. Samson Agbo, UNICEF's chief of child survival growth and development, who was in Jerusalem throughout the conflict. “You know what to do and what was required, but you could not do it. You just couldn't.”

A United Nations worker stands inside the UN compound that was struck by Israeli fire during the visit of UN Secretary-General Ban Ki-Moon in Gaza City on Jan. 20. Image by: Reuters/Suhaib Salem

This created what the head of operations in Gaza for the International Committee of the Red Cross, Pierre Kraehenbuhl, calls “a full-blown and major humanitarian crisis.”

Ambulance movement was severely restricted and normal health care ground to a near halt. Most international agencies relied on local staff who worked with little support and under great stress. Humanitarian workers had been denied access to Gaza since early November, leaving a dearth of international aid experts in the region when the fighting began.

That, coupled with the longstanding blockade of goods, left Gaza's health care system at a severe disadvantage.

The nongovernmental organization DanChurchAid ran its work mobile clinic and food distribution campaign through a local coordinator and a handful of volunteers. Yet, the local coordinator, Omar Almajdalawi, had to flee his home with his wife and 3 children moments before it was razed.

As a consequence, the organization has prioritized trauma and psychosocial counselling for aid workers and the local population. DanChurchAid Middle East Coordinator Malene Sonderskov says a campaign to treat trauma is key because trauma often forms the roots of other problems such as poor eating habits, lack of motivation and vulnerability to those who seek fresh recruits to commit violence.

“Gaza has the highest prevalence of traumatized children in the world,” he says. “That is important to so many of the issues we are addressing.”

With a measure of always-fragile peace in place, relief workers are now struggling with a humanitarian supplies situation that has gone from famine to feast. A massive influx of relief supplies has now overwhelmed the logistical abilities of agencies and local authorities to deliver them to Gaza residents. “To be honest, there is enough [aid] in the pipeline to supply Gaza for the next half century,” says Tony Laurance, head of office for the WHO's Gaza mission, from Jerusalem. “On many items we have far in excess of what we need.”

That creates its own problems, particularly melding aid to actual needs on the ground. “It's generous,” Laurance says, “but it's a classic case of an uncoordinated donor response, and it's not always helpful.”