Yara M. Asi
+972 Magazine / October 14, 2020
The strip’s rehabilitation already demanded ‘herculean efforts.’ With the spread of COVID-19, action is imperative.
In 2012, five years after Israel imposed a land, air, and sea blockade on Gaza, the United Nations released a landmark report warning that the strip was well on its way to becoming uninhabitable by 2020, based on any modern standard of living.
The recommendations were clear: Gaza needed tens of thousands of housing units, a doubling of electricity provision, a significant investment in water and sanitation infrastructure, and hundreds more schools and health centers. “To ensure that Gaza in 2020 will be ‘a liveable place,’” the report concluded, “on-going herculean efforts by Palestinians and partners in such sectors as energy, education, health, water and sanitation, need to be accelerated and intensified in the face of all difficulties.”
But this herculean effort never occurred. Instead, the blockade continued and living conditions became even more intolerable, creating a confluence of public health crises. Then, COVID-19 hit.
At the onset of the pandemic, many Palestinians perceived Gaza’s isolation almost as a benefit. Israel and Egypt control and monitor the strip’s only border crossings, while Hamas instituted strict quarantine protocols (up to 21 days) for any person who entered Gaza.
While tourists were thought to have brought the first coronavirus cases into the occupied West Bank in early March, Gaza’s first cases were recorded weeks later from men who were returning to Gaza through Egypt, and who were immediately quarantined. It was in late August, however, that the first instances of community spread were detected. As of Oct. 14, there were more than 4,000 cumulative confirmed cases and 26 deaths. Now, Palestinians in the strip are under a “double lockdown” — caged in by Israel and Egypt, and restricted from moving within the territory.
Unlike almost every other public health dimension, Gaza is performing better on COVID-19 containment than the West Bank, which has reported tens of thousands of cases and hundreds of deaths. The multiple levels of isolation and lockdown have certainly been one component of what has so far been a low mortality rate in Gaza. Among other effects, the restriction on movement has also meant that labourers from Gaza do not cross into Israel for work, which has been a vector of transmission into the West Bank population.
Another factor that may play a protective role is the significant proportion of younger people. While this youth bulge is devastating for employment and educational opportunities, evidence so far suggests that younger populations are less likely to report the more dire symptoms of COVID-19. The median age in Gaza is 18 years, and less than 7 percent of the population is above the age of 55. Gaza also does not have a culture of nursing homes and long-term care facilities, where the coronavirus has shown rapid spread that results in higher mortality.
However, it is clear to all that an outbreak in Gaza would be disastrous and almost guaranteed if there was uncontrolled community spread. The strip is an extremely dense urban environment with large multigenerational households, making social distancing difficult. Lack of basic needs like water and electricity hamper efforts to increase sanitation, as is required for an infectious disease. And with unemployment and poverty rates so high, it is likely that many families have at least one member who cannot afford to skip work and is therefore forced to leave the house.
A public health emergency
Public health, as described by the World Health Organization, is “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society.” It is more than just the number of physicians or hospital beds — although Gaza is deficient in both. It is about the multifaceted elements that contribute to a healthy life at the individual level, and the ability to weather health emergencies on the collective level.
A glimpse at Gaza’s recent history paints a picture of a territory where neither of these missions is possible. Israel’s latest war in Gaza in 2014 damaged or destroyed dozens of health facilities and schools, along with tens of thousands of homes. Worse yet, much of the destroyed infrastructure has never been repaired due to Israel’s import restrictions on construction materials.
In 2018, the World Bank reported that Gaza’s economy was in “free fall” with half the population living in poverty. The situation became so dire that residents organized weekly protests at the fence with Israel, dubbed the Great March of Return, demanding an end to the blockade and the return of Palestinian refugees to their historical land. Israeli snipers, tanks, and aircraft killed nearly 200 Palestinians and injured thousands more, many permanently. Gaza’s hospitals became even more overwhelmed, running out of basic supplies like gauze and IV bags.
Nearly 70 percent of households in Gaza were food insecure last year. Almost all the water produced by Gaza’s single aquifer is unfit for human consumption, and sewage is often dumped into the sea, washing up on beaches and overflowing into streets. This is not to mention the shortfall of hundreds of thousands of liters of fuel needed per month just to be able to keep hospitals and homes functional during power outages.
The capacity of Palestinian society to care for itself has also been severely crippled. Last year, 36 percent of medical permits to leave Gaza for advanced medical care were denied or delayed to the point where the patient missed their appointment. In late December, it was estimated that nearly 150,000 residents in Gaza had become addicted to drugs, with no sanctioned treatment or community center amenable to drug rehabilitation. One in 10 residents, and more than half of all children, suffer from some form of mental disorder, often related to war trauma.
We need a fundamental shift
The public health crisis has only deepened under the strain of recent political developments. In May, President Mahmoud Abbas announced an end to the Palestinian Authority’s civil and security coordination with Israel as a response to the threat of Israeli annexation. While some found it a suitable reaction, the unintended consequences were immediate: hundreds of Palestinians — including children — who needed to travel out of Gaza to receive advanced medical care were experiencing longer delays and confusion, in some cases even dying, while waiting for travel permits.
This has placed excessive stress on Gaza’s meagre health resources, and it means that those with illnesses that make them more susceptible to the worst effects of COVID-19 are left untreated. It also means that the sickest patients who are able to receive permits are entering more high-risk scenarios for COVID-19 spread by traveling across borders. It is no wonder that, in June, Physicians for Human Rights-Israel described the situation as “on the brink of medical chaos.”
Unfortunately, this is only threatening to get worse. By late September, Gaza’s Health Ministry reported a 65 percent shortage of laboratory supplies (including COVID-19 testing kits). Nearly a third of essential medical supplies and 47 percent of essential drugs are at zero stock; many more are set to run out before the end of the year.
While import restrictions and the destruction of local factories are part of the problem, pharmaceuticals in Gaza are supposed to be provided by the Palestinian Health Ministry in Ramallah. Agreements with the PA dictate that 40 percent of Palestine’s pharmaceuticals (mostly supplied by international actors) should be shipped to Gaza, but according to a spokesperson for Gaza’s Health Ministry, less than 7 percent actually reach the strip.
These daunting facts bring us back to the question of Gaza’s “liveability.” For years, well-intentioned reports have cautioned about the strip’s “impending” collapse. But this endless forecasting has only given cover to the public health crises that exist right now, stalling our impetus for action until it was too late. These crises are unacceptable in the current pandemic, but they were just as unacceptable at any point in the last 20 years.
Whether it is a future war, the outcomes of climate crisis, or another pandemic, we can be sure that Gaza will face more threats to public health in the coming years. A fundamental shift in how we balance the national security of one population with the human security of another is essential. Ultimately, Gaza is an inherently livable place, as evidenced by the 2 million Palestinians residing there — but we need to make it so.
Yara M. Asi, PhD, is a post-doctoral scholar in Health Management and Informatics at the University of Central Florida, and a 2020-2021 Fulbright US Scholar to the West Bank