Warzone Healthcare Struggle: The Case of Gaza— A Commentary

The chronic and rapidly evolving nature of Israel’s ongoing attacks on Gaza makes it challenging to ac- curately quantify the unprecedented destruction that has ensued. This is the longest-standing con- flict in recent Middle Eastern history. In 2007, Is- rael imposed a siege on Gaza, significantly hinder- ing the provision of healthcare services, and the re- cent aggressions since October 7th, 2023 have had disastrous outcomes [1]. By September 2024, more than 41,000 Palestinians had been killed and more than 96,000 injured [2]. Statistics indicate that 90% of the population have faced displacement, while 96% have struggled with food insecurity [2]. There has been significant damage to Gaza’s infrastruc- ture, including housing, agricultural facilities, and water and sanitation systems [2]. The education system has suffered an alarming loss of students, staff, and school buildings [2]. A spatial statistical analysis found that, within the first seven weeks af- ter October 7th, 2023, the damage from Israeli at- tacks was within 25 metres of 70.1% of health fa- cilities, 75.8% of education facilities, and 51.3% of water facilities, suggesting violations of interna- tional humanitarian law (IHL) [3]. Correspondence published in 2024 reported disturbing death counts, suggested these were likely to be underestimates, warned of indirect deaths, and predicted a grave death toll in the event of no ceasefire [4]. Echoing countless other researchers and international organ- isations, it urged for an immediate and permanent ceasefire [2,4]. Israeli authorities have significantly hindered Pal- estinians’ access to health care, even before the most recent aggressions [5], and the latest attacks have further damaged Gaza’s healthcare system. By July 2024, more than 490 attacks on healthcare fa- cilities had been recorded [2]. A study assessing the geospatial proximity of 2000-lb bomb Mohamed detonations found that, within the first six weeks Mahmoud Marey (Muhammedmarei2003@gmail.com) is with the Faculty of Medicine, Alexandria University, Alexan- dria, Egypt and Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA; Malak A. Hassan (mala- khassan786@gmail.com) is with the Faculty of Medicine, Al- exandria University, Alexandria, Egypt. DOI: 10.52609/jmlph.v5i3.191

of Israel’s attacks, more than 83% of Gaza’s hospi- tals fell within the infrastructure damage and injury range of detonated bombs, 25% being within lethal range [6]. Within the same time-frame, 38 bombs were dropped within 800 m of hospitals in the evac- uation zone, demonstrating that nowhere is safe [6]. By September 2024, almost 1,000 medical person- nel had been killed and more than 300 others had been detained by the Israeli army [2]. Humanitarian organisations in Gaza have struggled to provide ser- vices due to restricted mobility, disrupted telecom- munications, frequent checkpoints, destruction of facilities, and even the arrest of healthcare provid- ers [7-9]. The lack of personal protective equipment (PPE) and the unsanitary conditions have made in- fection control nearly impossible [10], while fuel shortages, electricity outages, damaged roads, and security risks have impeded emergency medical services [6,10]. Moreover, the loss of family mem- bers, colleagues, and patients has placed a heavy emotional burden on healthcare workers in Gaza [11]. The ethical triage dilemma amidst limited re- sources further exacerbates the psychological im- pact of the war on medical personnel, and the lack of international support has led to feelings of disap- pointment and isolation [11]. Not only have these factors restricted the adequate delivery of medical care; they have also endangered the lives of healthcare workers. The heightened transmission of infectious diseases resulted in 3,551 cases of diarrhoea, 8,944 cases of scabies and lice, 1,005 cases of chickenpox, 12,635 cases of skin rash, and 54,866 cases of upper res- piratory infections, from October to November 2023 alone [11]. Furthermore, the emergence of po- liovirus in Gaza for the first time in 25 years, amidst mass displacement, was alarming [12]. Destroyed clinics, drug shortages, repeated displacement, mal- nutrition, poor sanitation, communication black- outs, psychological distress, and the lack of medical supplies have left a number of high-risk groups par- ticularly vulnerable, including dementia patients, pregnant women, newborns, children, and patients with chronic illnesses [13-16]. Despite our best at- tempts to capture the impact on the health system,

this is not an exhaustive list. There have been sig- nificant hurdles in data collection and reporting, making it difficult to assess the true extent of the damage. Nevertheless, the picture is one of moral failure. IHL mandates that all parties in armed con- flicts refrain from targeting hospitals, healthcare providers, and humanitarian aid workers [17,18]. Parties must agree on and establish safe zones to protect civilians, ease identification of victims, and evacuate patients to safe areas with better healthcare facilities [18]. Those who violate these humanitarian laws are considered war criminals and should be held to account by international courts [17]. In recent years, we have witnessed the distressing humanitarian crisis caused by the Russia-Ukraine conflict. European nations have supported Ukraine with financial and humanitarian aid, medical teams, and refugee programmes, all of which interventions have been crucial in alleviating some of the chal- lenges imposed by military aggressions [19]. In 2020, despite the war in Syria and the COVID-19 pandemic, UNICEF managed to deliver polio vac- cinations to nearly 400,000 children [20]. In 2018, the United Nations (UN) was the primary mediator of the Hudaydah ceasefire in Yemen, facilitating the delivery of medical aid and healthcare services [21]. In light of the above-mentioned precedents, we call for a similar international response to Gaza’s ongoing humanitarian crisis. We urge the World Health Organization (WHO) to coordinate a large-scale medical evacuation opera- tion in Gaza to facilitate disease control and im- prove access to healthcare. The UN must establish safe zones to safeguard civilians and health work- ers, and to ensure unrestricted access to medical aid under international agreements. Doctors Without Borders/Médecins Sans Frontières (MSF) should expand its presence by establishing field hospitals near the borders to provide critical trauma care. We note a dire need for international medical volunteer teams, under UN supervision, to provide essential healthcare services and address the shortage of hu- man resources. In addition, such teams should aim to document violations against healthcare providers to ensure the responsible party is held accountable. Future interventions should also aim to improve the mental health and well-being of healthcare workers in Gaza [11]. This may be our final opportunity to save the re- maining Palestinians in Gaza. It is our moral imper- ative to advocate for the civilians impacted by the

ongoing attacks, in alignment with the principles of medical ethics. We wish eternal peace for the vic- tims, a quick recovery for the injured, strength and patience for their families, and a brighter future for this geographical region.