William C. Lieber, Faraan O. Rahim, Bhav Jain, Devesh Shah, and Mohammad Z. Sahloul
In the wake of the devastating attack by Hamas on Israeli soil on October 7, which resulted in over 1,200 Israeli deaths and the capture of 240 hostages, the Israeli government pledged swift retaliation against Hamas. On October 9, Israel imposed a total blockade on Gaza, cutting off food, water, electricity, fuel, and medicine. Additionally, on October 12, the Israeli government commanded 1.1 million Palestinians to evacuate North Gaza within 24 hours.1 Israel began expanding ground operations on October 27, signaling the beginnings of an invasion into Gaza.2 As of November 27, the Government Media Office of Palestine has reported that 14,800 Palestinians have been killed, with an additional 1.8 million Palestinians internally displaced.3
Furthermore, the siege of Gaza has caused fuel shortages that threaten the lives of thousands of patients who are now unable to evacuate from hospitals. Ventilators, dialysis machines, and incubators have been rendered inoperable by electricity and fuel shortages. Many hospitals have sustained damage from the war, including the Al Shifa, Al Quds, and the Ahli Arab hospital, the latter of which on October 17 was damaged by a stray rocket suspected to have been fired by Hamas.4 Many sick, chronically ill, and disabled patients are being turned away from hospitals in North Gaza, forcing them to flee on foot and seek refuge in similarly overwhelmed and disease ridden UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) shelters in the South.5 Humanitarian pauses beginning November 24 have provided UN agencies and Red Crescent Societies opportunities to increase aid delivery.6
Given the high death tolls ravaging both Palestinian and Israeli civilians, it is imperative that civilian access to healthcare stands as a global priority amidst this deadly and close-proximity warfare. As foreign actors deliberate aid and action, a healthcare-oriented perspective will serve to establish fundamental guidelines that the international community can leverage when mobilizing to protect the citizens of Palestine and Israel.
First, the international community must continue to facilitate the safe passage of medical supplies, personnel, and other resources into Gaza. Over the past month, Gazan medical facilities have suffered extensive damage. As of November 12, UNFPA, UNICEF and WHO have reported at least 137 attacks on health care in Gaza, resulting in 521 deaths, including 16 deaths of health workers on duty. The UN must strongly condemn future attacks against hospitals and other healthcare facilities in both Palestine and Israel, as such actions significantly increase the toll of innocent lives lost and are violations of International Humanitarian and Human Rights Law and Conventions.7 Furthermore, foreign governments and NGOs must continue to direct aid towards protecting health infrastructure and healthcare personnel disseminating aid, such as UN officials and humanitarian volunteers from Médecins Sans Frontières and the Red Cross. These organizations can in turn supply ambulances, doctors, and emergency medical supplies to local systems, such as the Palestinian Red Crescent Society and the United Hatzalah. While the convoys of aid beginning October 21 to Gaza have provided some support, foreign governments must continue to lobby for the safe passage of NGO-supplied resources, including vital supplies of fuel. If safe passage for healthcare resources and workers cannot be guaranteed on the ground, Egypt, Jordan, and other neighboring countries could facilitate NGO-deployed drones to provide safe and cost-effective delivery of medical supplies to healthcare workers and civilians in otherwise inaccessible warzones, similar to batches of aid air dropped by Jordan to field hospitals.
Second, healthcare access for the sick and wounded must be expanded in neighboring countries. On November 1, over 300 dual Egyptian-Palestinian passport holders and critically injured Gazans were allowed into Egypt. It is expected 7,500 passport holders will be evacuated in the next two weeks using buses and the re-opened Al Arish airport. Jordan should consider joining Egypt in allowing wounded Gazans to enter for temporary healthcare services, particularly for advanced surgeries that Egypt is struggling to accommodate.8 Public health organizations should involve refugee planners in the creation of one-stop access points to address dire first aid needs while ensuring that Gazans will be able to return to Gaza and do not remain displaced.
Finally, the world must prepare to respond to both the impending influx of refugees and the resulting need to build capacity in Gaza for those refugees to return. There will be high numbers of civilians from across the region seeking refuge due to civil unrest, particularly as conflict pauses are implemented to allow civilians to escape combat zones.9 During the violence, the displacement of people must be handled with extreme caution to avoid demographic changes in the Gaza Strip. Forcible displacement should be avoided where possible, however, where forcible displacement is unavoidable, host countries should develop inclusive policies wherein refugees are purposefully integrated to avoid overburdening healthcare systems and to ensure accessibility of care.
Western countries providing aid should strive to support their counterparts in the Middle East to provide resources for refugees in the interest of international cooperation. In addition, to avoid tension within host communities, humanitarian aid should be allocated in a way that is economically beneficial for countries hosting refugees, a measure that has shown promise in fostering positive relationships between Ugandans and Sudanese refugees.10 Moreover, the Syrian refugee crisis highlighted numerous weaknesses in refugee health care systems in recipient countries.11 Thus, after the violence of the Israel-Palestine conflict subsides, aid should be channeled towards rebuilding a destroyed Gaza to facilitate the return of the maximum number of Palestinians to their homes. All organizations involved in refugee planning and rebuilding healthcare capacity in Gaza must ensure providers are trained in elements of trauma-informed and culturally appropriate healthcare.
Over the past month, there has been an outpouring of support from around the world for those suffering in the Israel-Palestine conflict. Yet without swift action, these sentiments cannot mitigate one of the most severe humanitarian crises of the century. In deciding future courses of action, it is imperative that international stakeholders consider their responsibility to uphold healthcare access for the innocent lives directly afflicted by the warfare and to welcome those seeking safe refuge abroad.
William C. Lieber is a researcher at the Duke Global Health Institute in Durham, NC, United States. Email: will.lieber@duke.edu
Faraan O. Rahim, BS is a researcher at the Duke Global Health Institute in Durham, NC, USA and the Pittsburgh School of Medicine in PA, United States.
Bhav Jain, BS is an MD candidate at Stanford Medical School and a researcher in the Stanford Department of Health Policy, CA, United States.
Devesh Shah is a researcher at the Duke Global Health Institute in Durham, NC, United States.
Mohammad Z. Sahloul, MD is a Pulmonary and Critical Care physician at the University of Illinois at Chicago, United States, and the co-founder and current president of MedGlobal.
References
- United Nations. UN expert warns of new instance of mass ethnic cleansing of Palestinians, calls for immediate ceasefire. (2023); Reuters. Israel ‘not successful’ in bid to minimize Gaza civilian casualties, Netanyahu says. (November 16, 2023). Accessible at: https://www.reuters.com/world/middle-east/israel-not-successful-bid-minimize-gaza-civilian-casualties-netanyahu-says-2023-11-17/#:~:text=WASHINGTON%2C%20Nov%2016%20(Reuters),Benjamin%20Netanyahu%20said%20on%20Thursday.
- R. Zvulun, Israeli army shows devastation in northern Gaza as invasion grinds on. (November 9, 2023). Accessible at: https://www.reuters.com/world/middle-east/israeli-army-shows-devastation-northern-gaza-invasion-grinds-2023-11-08/
- United Nations Office for the Coordination of Humanitarian Affiars. Hostilities in the Gaza Strip and Israel | Flash Update #52. (November 27, 2023).
- M. Biesecker, AP visual analysis: Rocket from Gaza appeared to go astray, likely caused deadly hospital explosion. Associated Press News. Accessible at: https://apnews.com/article/israel-palestinians-hamas-war-hospital-rocket-gaza-e0fa550faa4678f024797b72132452e3
- World Health Organization. Evacuation orders by Israel to hospitals in northern Gaza are a death sentence for the sick and injured. (October 14, 2023).
- See note 3
- World Health Organization. UNFPA, UNICEF and WHO Regional Directors call for immediate action to halt attacks on health care in Gaza. (November 12, 2023).
- Reuters. At least 320 foreign nationals and some wounded leave Gaza for Egypt. (November 1, 2023). Accessible at: https://www.reuters.com/world/middle-east/egypt-prepares-evacuees-gaza-arrive-through-rafah-crossing-2023-11-01/
- S. H. Nidal Al-Mughrabi, US says Israel agrees to daily pauses in Gaza attacks but fighting rages on. (November 9, 2023). Accessible at: https://www.reuters.com/world/middle-east/fierce-fighting-gaza-city-us-says-palestinians-must-govern-gaza-post-war-2023-11-09/
- Y.-Y. Zhou, G. Grossman, and S. Ge, “Inclusive refugee-hosting can improve local development and prevent public backlash”. World Development 166, 106203 (2023).
- N. El Arnaout, S. Rutherford, T. Zreik, et al. “Assessment of the health needs of Syrian refugees in Lebanon and Syria’s neighboring countries.” Conflict and Health 13, 31 (2019).