Gaza's health and humanitarian crisis

The Lancet, Volume 384, Issue 9941, Pages 389 - 390, 2 August 2014, doi:10.1016/S0140-6736(14)61125-9, Published Online: 31 July 2014

The conflict in Gaza has claimed hundreds of civilian lives and damaged or destroyed numerous health facilities. Kristin Solberg, who was in Gaza at the start of the war, reports.


A broken metal wheelchair stood in the ruins, crushed by the massive force of an explosion, its owner dead or in hospital. Nearby, footprints in blood marked the path of a caretaker who ran for help after flames engulfed the building. Elsewhere in the rubble were traces of the lives that had been quietly led here for years: a hair brush, a fan, a pencil case, a copy of Ali Baba and the Forty Thieves.
Such were the scenes at the Mabaret Palestine Society, a home for people with developmental disabilities in Beit Lahiya, northern Gaza, on the morning of July 12. A few hours earlier, the home had been hit by an Israeli missile. Survivors described a sudden explosion while the home's five residents and a caretaker gathered for suhoor, the last meal before sunrise in Ramadan. Two residents were killed immediately; their charred remains brought to a nearby morgue and wrapped in white shrouds.


One of the dead was 37-year-old Soha Abu Sada, who had lived in the home since her parents died 13 years ago. Her elder sister Sohaila explained that Soha had been born with severe mental disability and could not talk. “She didn't understand much, but she liked that I came to visit her”, she said, sitting outside the morgue, surrounded by desperate people looking for loved ones after the previous night's shelling. Crying, she asked a question which no one present could answer: “why?”, she said. “Why would they hit a home for disabled people?”


Civilian deaths


The war in Gaza, which began with air strikes on July 8 and escalated with a ground offensive 10 days later, has had a devastating toll on civilians—and on the tiny strip's already overstretched health facilities. As of July 27, 22 hospitals, clinics, and medical centres have been hit and damaged by shelling, according to the UN Office for the Cooordination of Humanitarian Affairs. According to WHO, nine ambulances are damaged, four hospitals have been forced to close after being shelled, and 27 primary health centres have stopped operating because they are in unsafe areas. Navi Pillay, the UN High Commissioner for Human Rights, warned that Israel may have committed war crimes in Gaza, citing strikes against homes and hospitals. She also condemned Hamas' indiscriminate firing of rockets into civilian areas in Israel.


Mahmoud Daher, head of WHO's sub-office in Gaza, told The Lancet: “There have been several direct attacks [on health-care facilities in Gaza] and many indirect attacks where damages have been caused by nearby explosions.”


More than 1100 Gazans, mainly civilians, have been killed in Operation Protective Edge, which Israel launched to stop the firing of rockets from Gaza after weeks of mounting tensions spurred by the kidnapping and killing of three Israeli youths in the West Bank. A quarter of the dead are children, according to Gaza's health authorities. 53 Israeli soldiers and three civilians have also been killed.


Health facilities attacked


Among the dead in Gaza are at least six health workers, according to WHO. Three of them were paramedics; killed while rescuing injured people from ruins or while driving through empty streets between scenes of destruction and hospitals. Another 16 health workers have been injured.


The deadliest attack on a health facility was the shelling of al Aqsa hospital in Deir al Balah in central Gaza on July 21. The hospital came under direct tank fire several times, and the surgical ward, the intensive care unit, and pieces of life-saving equipment were severely damaged. Four people died instantly and six died later from injuries, according to WHO. Another 70—including patients, their companions, and hospital staff—were wounded. “This incident is yet another illustration of the dangers faced by health-care personnel, patients, ambulances, and hospitals in the current conflict in Gaza”, said Christian Cardon, head of the International Committee of the Red Cross sub-delegation in Gaza, in a statement. “Even in the midst of warfare, people must be able to receive medical care in safety.”
But in this tiny strip of land, where 1·7 million people live in a fenced-off area the size of Detroit, no place is considered safe. A few days later, an Israeli shell exploded outside al Durra Children's Hospital in Gaza City after a targeting of a nearby building, killing a 2-year old in the intensive care unit.


Al Wafa Medical Rehabilitation Hospital was hit several times. “We thought it was a safe haven”, director Basman al-Ashi told The Lancet. The hospital received several warnings from the Israeli Defence Forces (IDF) to evacuate. “I told them many times that my patients cannot evacuate because they are paralysed, some of them are unconscious. And there is no place to take them because this is the only rehabilitation hospital in the area, and other hospitals are overwhelmed”, said al-Ashi.


The last warning came at 9 pm on July 17, and 5 minutes later two missiles hit, said al-Ashi. The electricity went off, a fire started, and under continuing shelling, the hospital staff evacuated all 17 patients to another hospital. No patients or staff were injured, but equipment worth US$10 million and the building were destroyed, al-Ashi said.
“Of the 5000 injured [now above 6000] in Gaza, about 30% will be in need of rehabilitation, but there is no offer for them now”, al-Ashi said. He denied that the hospital was used for a military purpose as claimed by the IDF.


Israel says Hamas—which has ruled Gaza since 2007—and militant group Islamic Jihad use civilians as “human shields” and store weapons in schools, mosques, and hospitals. “Civilian casualties are a tragic inevitability of [Hamas'] brutal and systematic exploitation of homes, hospitals and mosques in Gaza”, the IDF said in a statement.
After the strike on Wafa hospital, IDF said, “Hamas has turned Wafa Hospital into a command centre and rocket launching site. Hamas has fired at Israel and IDF from this hospital”.


IDF said that it had targeted a cache of anti-tank missiles in the al Aqsa hospital's “immediate vicinity”. It said it was investigating what had been the target for the strike on the Mabaret Palestine Society home.


“Israel has not provided enough information about the target to justify such damage to the hospital”, Human Rights Watch said in a statement after the strike on Wafa hospital. “Israeli forces repeatedly warned hospital staff to evacuate since July 11, but issuing warnings did not remedy the illegality of repeatedly striking a hospital without a lawful military justification.”


At the Mabaret Palestine Society, three residents and the caretaker on night duty were injured—two critically. They were brought to the burns unit at Gaza's largest hospital, Al Shifa. In intensive care was 25-year-old Ahmad who has cerebral palsy. In a coma, doctors were unsure if he would survive. “He's inhaled fire”, said Nafez Abu Shaban, head of the unit. “His condition is very serious.”


Caretaker Salwa Abul Qumzan, hospitalised with burns covering 20% of her body, described the attack: “There was a loud explosion and suddenly there was fire everywhere, nothing but fire. I ran out and called to the neighbours: ‘save the children!’”


Director Jamila Elwaa said neighbours told her there had been a warning—a so-called “knock on the roof” warning shot intended by the IDF as a message to evacuate. “But the caretaker didn't understand what it meant”, Elwaa said. Even if the caretaker had understood the signal, she would have struggled to evacuate the severely disabled patients in time, she added.


Already dire


Hospitals are overstretched amid the sudden influx of injured patients. In June, a few weeks before the war, a report from the UN Relief and Works Agency for Palestine Refugees (UNRWA) warned of a deepening crisis in Gaza's health system. The Israeli blockade—in place since mid-2007—a halt in the tunnel trade through Egypt and insufficient cash flows following the establishment of the Palestinian reconciliation Government, had left hospitals short on essential medical supplies, unable to pay their staff, and struggling to buy enough fuel for generators and ambulances to even maintain emergency services.


The situation was already so dire that Al Shifa hospital stopped all planned surgeries from mid-June and did only life-saving emergency surgeries from July 1. Supplies and stocks of essential drugs, intravenous fluids, disposables, spare parts, laboratory chemicals, and instruments could no longer sustain the needs at Shifa, where staff had not been paid since March. Then war came.


“It is obvious that injured patients have died as a result of lack of equipment and medicines”, said Mads Gilbert, a Norwegian anaesthesiologist working in Shifa and author of the UNRWA report. “But what is lacking has been compensated by a great effort by health workers, day and night.”


“We are operating in the corridors”, said Sobhi Skaik, medical director at Shifa hospital on the most deadly day of the war, when more than 60 people were killed in the Shujaya neighbourhood east of Gaza City. “But we are coping.”


On July 28, the outpatient clinic of Shifa hospital was hit, injuring some of those inside. Eyewitnesses and doctors present said the strike came from an Israeli drone. IDF blamed Hamas, saying a misfiring rocket hit the hospital. Minutes later, ten people including at least eight children were killed in a strike on a playground.