Notes for Health Care Professionals Facing Gaza’s Health Crisis

In 2007, Israel and Egypt tightened the blockade on Gaza, which begun in 2000. The Israeli Knesset declared that “the movement of goods into the Gaza Strip will be restricted. The supply of gas and electricity will be reduced, and restrictions will be imposed on the movement of people from the Strip and to it.”(1)(2) The humanitarian impact of this tightened blockade is well documented; 96% of the water is unfit for human consumption (3), 40% of households are food insecure (3), unemployment rates are over 40% (4), exports are disallowed by the blockade and hence economic development has been paralyzed.(3) Electricity cuts mean most homes, businesses and hospitals have power only 4 to 6 hours per day.(5) According to one UN agency, Gaza will “become uninhabitable by 2020 if current economic trends persist.” (6)(7)

Despite the deadly effects of the blockade, health professionals in Gaza nonetheless must continue to perform their work and attempt to save lives. Below are outlined three specific impacts of the blockade and efforts to maintain health care in spite of them. These are (i) the lack of power to run the hospitals, (ii) lack of referral of complex patients to certified specialists and (iii) lack of certified specialists within Gaza.

Lack of Power to Run the hospitals

Blackouts have brought “Gaza’s health system close to collapse” (8); in August (2018) electricity was available only 5 hours per day (9). Surgeries are cancelled; reductions in cleaning, catering and sterilization services increase risk of surgical infections.(10) Dialysis machines can’t run, putting patients’ lives at risk. (11) Lack of electricity has forced seven hospitals to suspend all services for patients in early 2018. (12)

How do surgeons operate in the dark? How do emergency physicians set a fractured leg with no light? What happens to the child on a ventilator in an intensive care unit when power shuts off? Lack of electricity in hospitals increases suffering and death.

In addition to the direct impact of power shortages on health care facilities, blackouts disrupt water treatment facilities; infectious diarrhea and other waterborne illnesses remains a significant cause of morbidity in the Gaza strip. (13)

“What happens to the child on a ventilator in an intensive care unit when power shuts off? Lack of electricity in hospitals increases suffering and death.”

Lack of Referral of Complex Patients to Certified Specialists

Prior to 2007, movement and access to areas outside Gaza was already “extremely limited,” (14), but sometimes patients requiring subspecialist care (eg. Cardiology, plastic surgery, psychiatry) were referred to physicians outside Gaza, in hospitals in Egypt, Israel or the West Bank. Since 2007, the “permits issued by Israel for Palestinians seeking vital medical treatment outside Gaza” has reached a “record-low rate” as “Egypt continues closure of the Rafah border with Gaza…caus[ing] additional suffering.”(15)

Allegations that the Israeli Security Agency (Shin Bet) interrogates Palestinian patients seeking permission to travel from Gaza to Israel for medical aid (and the fear that non-cooperation would lead to denial of treatment) (16) further discourage Palestinians from applying for permits.

Lack of Certified Specialists Within Gaza

Palestinian medical students are often ineligible to work in Israeli hospitals to enhance their training (17) and most often lack the financial means to go abroad. There are numerous specific challenges for Palestinian medical students to get further clinical training, including permit rejections, long wait times, mistreatment and delays at checkpoints during commute to hospitals. (18) “Under the policy of complete closure imposed since June 2007, Palestinians from Gaza who once constituted some 35% of the student body at universities in West Bank are virtually absent from West Bank education institutions.” (19)

The lack of a reliable referral system for complex patients has increased the demands on physicians in Gaza to provide subspecialist care never having been trained to do so. In 2005, Dr. Hassan* worked as a family doctor in his own outpatient clinic, and United Nations clinics in Rafah, a refugee camp in the Southern Gaza Strip. He frequently managed simple conditions such as upper respiratory tract infections, cuts and bruises, headaches and diarrhea. In 2007, when the blockade tightened, he was instructed by local health authorities to provide kidney care to patients suffering from a variety of kidney diseases, including dialysis treatments, or complex immune system modulating medications. These specialized treatments would normally require a minimum of 2 dedicated years of additional study, and often longer. Dr. Hassan has tried multiple times to leave Gaza for additional training- he has been denied repeatedly. (20)

Other

The blockade has impaired the health care system in numerous other ways; chronic (and worsening) shortages of critical medications, supplies and infrastructure remain a reality. (21)(22) These impairments are not the focus of this report, and are well described elsewhere.

Medical Responses to Maintaining Health Care under Blockade

Lack of Power to Run the hospitals

An ideal solution to overcome hospital blackouts would allow inexpensive, reliable and uninterrupted energy delivery to critical hospital areas such as the emergency room, dialysis units, surgery theatres, and intensive care units. Gaza’s energy needs are about 400 to 600 megawatts for complete 24 hour supply (23,24)); supply usually comes from a diesel power plant in Gaza (60 to 140 megawatts), Egypt (27 megawatts), and Israel (125 megawatts). (25–26) Any solution would require a decrease in Gaza’s need or an increase in supply from any of the three sources (Gaza, Egypt or Israel). Given the serious adverse consequences already realized in Gaza, a further reduction in need is impractical and would further jeopardize lives. Israel and Egypt’s supply of electricity continues to be insufficient and unreliable (25,26). The power station in Gaza is also a frequent target of Israeli attacks (23), resulting in suboptimal operations. Indeed, the sole power station in Gaza recently had to close, further worsening the electricity crisis. (27)

If the pre-existing energy sources are not reliable to deliver the required energy, innovative strategies are required to create new sources to meet the demand.

EmpowerGaza (28), a Canadian collaborative initiative between concerned Canadians and Islamic Relief Canada that succeeded in the installation of solar energy systems on three of Gaza’s largest health care facilities. Similar systems have been delivered to three other health care facilities (29–31). Where installed, the solar systems have had a dramatic impact on the continuous supply of power in the hospital, with an additional benefit of decreased dependence on fuel consumption to operate backup generators. This has already saved lives and prevented suffering for many patients[1] .

“Financial support for solar systems in Gaza hospitals is urgently needed to overcome death and suffering caused by blackouts.”

Thus, a solution to the lack of power in hospitals has already been successfully piloted, and is scalable if the money were available. However, the current work completed represents a fraction of what’s needed for Gaza’s hospitals’ electricity needs. A recent request by physician Dr. Tarek Loubani to the Canadian government for CAD$15 million (32) to complete solar energy systems for all Gaza’s health care facilities remains unanswered. Financial support for solar systems in Gaza hospitals is urgently needed to overcome death and suffering caused by blackouts. As a health care professional, while in Gaza I will continue to meet with health care professionals to maintain current systems and to create new systems of solar power in health care facilities.

Lack of Referral of Complex Patients to Certified Specialists

Restriction to physician movement limits access to training opportunities and continued education. When physicians from outside Gaza visit, they not only transfer knowledge and skills, but also learn themselves. Organizing these relationships is essential for sustained educational development; a number of groups have already organized including the Palestinian American Medical Association (PAMA), Foundation for International Development of Family Medicine in Palestine (FIDFMP), Doctors of the World and PalMed Europe (Palestinian Physicians’ Association in Europe). These groups serve a number of functions, including medical missions to Gaza, training health care professionals from Gaza, and promoting health care in Gaza. Furthermore, their availability for discussion of complex patients can help to bridge the gap of certified specialists in Gaza, until Gaza is able to have their own specialists trained. Communication via email and WhatsApp facilitate Gaza physicians consulting subspecialists from outside Gaza, in large part from connections made by these organizations.

Efforts to organize in Canada are ongoing and should facilitate greater connectivity (and subsequent consultation) soon. A number of Canadian physicians are involved in these efforts.

As a general internal medicine and nephrology (“kidney medicine”) physician, I have been teaching the medical school nephrology curriculum to Gaza medical students annually since 2014. I will be delivering the curriculum again this year, in September 2018. More board-certified physicians need to commit to come to Gaza to teach in the medical school: While physicians in Gaza are resilient and determined, there continue to be gaps in the medical school curriculum that require subspecialist guidance.

There are currently no board-certified nephrologists in Gaza, so each time I am in Gaza, I present a kidney medicine topic as requested by doctors at the largest hospital in Gaza (Al-Shifa hospital in Gaza city).

“More board-certified physicians need to commit to come to Gaza to teach in the medical school”

Lack of Certified Specialists Within Gaza

While visits to Gaza from certified subspecialists are needed, a health care system created by and for Palestinians would have their own physicians certified. Since there are currently only a few subspecialty training programs in Gaza, two potential models can provide subspecialty certification for physicians from Gaza. The first model involves a sustainable team of international physicians visiting and staying in Gaza, training local physicians to enhance local physicians’ skills and knowledge. Such sustainable efforts are rare, but have been implemented in Gaza. For example, a recent initiative by the Qatar Red Crescent Society will train local physicians in cardiac surgery, neonatology, and urology.(33)

On the other hand, training Gaza physicians outside Gaza exposes them to the potential that can be realized with optimal available medications, equipment and supplies; in turn, physicians returning to Gaza could have world class experience and then more effectively advocate to secure these resources. Similarly, training in a reputable academic training program outside Gaza can spearhead collaboration between institutions; this in turn leads to academic partnerships that make securing such resources less difficult. One example of training Palestinian physicians in a world class institution is the Palestinian Healthy Child Fellowship Program at SickKids Hospital in Toronto; over 10 physicians trained in this program have returned to Palestine, some of whom have been promoted to senior roles in long term health care system planning in Palestine.(34)

“International physician training programs must prioritize training of physicians from Gaza.”

While the Palestinian Healthy Child Fellowship Program has effectively trained Palestinian pediatric subspecialists, there remains a gap in meeting the need for adult subspecialists in Gaza. Efforts to meet this demand in Canada have recently led to a board certified nephrologist, who shall return to Gaza in early 2019. Recent assessment of the health care needs in Gaza indicate that the highest priority training needs are (in order from 1 to 15) Oncology, Pediatric surgery, Pediatric radiology, Orthopedic endoscopy, Vitreoretinal surgery, Pediatric nephrology, Vascular surgery, Rheumatology, Surgical oncology, Orthopedic surgery, Pediatric neonatal anesthesia,. Emergency medicine, Critical Care Medicine, Infectious Diseases and Neonatology.(35) International physician training programs must prioritize training of physicians from Gaza.

There are ongoing efforts to secure training opportunities for Gaza physicians in Canadian training programs; in September (2018), I will be interviewing potential candidates in Gaza for a number of training positions.

If you are interested in supporting solar power projects in Gaza’s hospitals, or supporting training of physicians from Gaza, contact Dr. Ben Thomson at ben@benthomson.org

This is the first in a series of articles on the impact of Lack of Power to Run the hospitals, Lack of Referral of Complex Patients to Certified Specialists, and Lack of Certified Specialists Within Gaza. With each update, the challenges, successes and failures of our work will be discussed.

References

1. Amira Hass. 2012. 2,279 Calories per Person: How Israel Made Sure Gaza Didn’t Starve. [ONLINE] Available at: https://www.haaretz.com/.premium-israel-s-gaza-quota-2-279-calories-a-day-1.5193157. [Accessed 24 August 2018].

2. State of Israel: Ministry of Defense (Unofficial translation by Gisha). 2012. AAA 3300/11 Ministry of Defense v. Gisha “Food Consumption in the Gaza Strip — Red Lines” Presentation. [ONLINE] Available at: https://www.haaretz.com/resources/Pdf/red-lines.pdf. [Accessed 24 August 2018]

3. United Nations Office for Coordination of Humanitarian Affairs. 2017. 2018 Humanitarian Needs Overview: Occupied Palestinian Territory. [ONLINE] Available at: https://www.ochaopt.org/sites/default/files/hno_20_12_2017_final.pdf. [Accessed 24 August 2018]

4. The World Bank. 2017. Economic Monitoring Report to the Ad Hoc Liaison Committee- September 2017. [ONLINE] Available at: https://www.worldbank.org/en/country/westbankandgaza/publication/economic-monitoring-report-to-the-ad-hoc-liaison-committee-september-2017. [Accessed 24 August 2018].

5. Mersiha Gadzo. 2017. Gaza power cuts: ‘This is the worst it’s ever been’. [ONLINE] Available at: https://www.aljazeera.com/indepth/features/2017/06/gaza-power-cuts-worst-170615075120345.html. [Accessed 24 August 2018]

6. United Nations Conference on Trade and Development. 2015. Gaza could become uninhabitable in less than five years in wake of 2014 conflict and ongoing de-development, according to new UNCTAD report. [ONLINE] Available at: http://unctad.org/en/Pages/PressRelease.aspx?OriginalVersionID=260. [Accessed 24 August 2018]

7. United Nations Conference on Trade and Development. 2015. Report on UNCTAD assistance to the Palestinian people: Developments in the economy of the Occupied Palestinian Territory. [ONLINE] Available at: http://unctad.org/en/PublicationsLibrary/tdb62d3_en.pdf. [Accessed 24 August 2018].

8. Rebecca Ratcliffe. 2018. Gaza’s health system close to collapse as electricity crisis threatens total blackout. [ONLINE] Available at: https://www.theguardian.com/global-development/2018/jan/03/gaza-health-system-collapse-electricity-crisis-threatens-total-blackout. [Accessed 24 August 2018].

9. United Nations Office for the Coordination of Humanitarian Affairs: Occupied Palestinian Territory. 2018. Gaza Strip electricity supply (2018, August). [ONLINE] Available at: https://www.ochaopt.org/page/gaza-strip-electricity-supply. [Accessed 24 August 2018]

10. Ahmad Kabariti. 2017. Surgeries cut by one-third in Gaza’s main hospital. [ONLINE] Available at: https://electronicintifada.net/content/surgeries-cut-one-third-gazas-main-hospital/20601. [Accessed 24 August 2018].

11. Palestinian Center for Human Rights. 2018. Life under siege: Electricity cuts put dialysis patients at risk. [ONLINE] Available at: https://pchrgaza.org/en/?p=9255. [Accessed 24 August 2018].

12. Wissam Nassar. 2018. 7 hospitals in Gaza shut down due to power shortage. [ONLINE] Available at: http://www.xinhuanet.com/english/2018-01/31/c_136939929_2.htm. [Accessed 24 August 2018].

13. United Nations Relief and Works Agency. 2009. Epidemiological Bulletin for Gaza Strip. [ONLINE] Available at: https://reliefweb.int/sites/reliefweb.int/files/resources/3FD25B7421191DB5492575C4000B29F4-Full_Report.pdf. [Accessed 24 August 2018].

14. United Nations Office for the Coordination of Humanitarian Affairs. 2006. The Agreement on Movement and Access One Year On. [ONLINE] Available at: https://reliefweb.int/sites/reliefweb.int/files/resources/5C043703E4CAF188C1257237003CE281-ocha-pse-30nov.pdf. [Accessed 24 August 2018].

15. Human Rights Watch. 2018. Israel: Record-Low in Gaza Medical Permits. 54 Died in 2017 Awaiting Israeli Permit. [ONLINE] Available at: https://www.hrw.org/news/2018/02/13/israel-record-low-gaza-medical-permits. [Accessed 24 August 2018]

16. Toni O’Loughlin. 2008. Middle East: Israel’s secret police pressuring sick Gazans to spy for them, says report. [ONLINE] Available at: https://www.theguardian.com/world/2008/aug/04/israelandthepalestinians.middleeast1. [Accessed 24 August 2018]

17. Nir Hasson. 2013. Palestinian Medical School Grads Protest Exclusion From Israeli Hospitals The Al-Quds School of Medicine, east of Jerusalem, is considered neither Israeli nor foreign, leaving its graduates ineligible to take the Israeli licensing exam.. [ONLINE] Available at: https://www.haaretz.com/.premium-grads-from-palestinian-med-school-in-catch-22-1.5271497. [Accessed 24 August 2018].

18. Shahawy S, Diamondf M. Attitudes of Palestinian Medical students on the geopolitical barriers to accessing hospitals for clinical training: a qualitative study. Conflict and Health 2016: 10: 5.

19. Palestinian Center for Human Rights. 2010. The Illegal Closure of the Gaza Strip: Collective Punishment of the Civilian Population. [ONLINE] Available at: http://www.pchrgaza.org/files/2010/Illegal%20Closur.pdf. [Accessed 24 August 2018].

20. * Name changed to protect identity. I personally met this gentleman in February 2013, and multiple times since in Gaza strip.

21. Amira Hass. 2018. Gaza Health System Collapsing: 40 Percent of Medicine Runs Out. [ONLINE] Available at: https://www.haaretz.com/middle-east-news/palestinians/.premium-gaza-health-system-collapsing-40-percent-of-medicine-runs-out-1.5803856. [Accessed 24 August 2018]

22. Jack Khoury. 2018. Gaza Health Crisis: Doctors Struggle to Treat Hundreds of Wounded Amid Shortage of Beds. [ONLINE] Available at: https://www.haaretz.com/middle-east-news/palestinians/.premium-gazan-surgeons-cite-inhuman-conditions-amid-ocean-of-wounded-1.6093667. [Accessed 24 August 2018]

23. Gil Ronen. 2014. Gaza’s Only Power Plant Knocked Out. [ONLINE] Available at: http://www.israelnationalnews.com/News/News.aspx/183470. [Accessed 24 August 2018].

24. Hedy Cohen. 2016. Quartet representative: The state of water, electricity, and sewage in the Gaza Strip also affects Israel.. [ONLINE] Available at: https://en.globes.co.il/en/article-israel-turkey-eager-to-rebuild-gaza-1001136597. [Accessed 24 August 2018].

25. Jeffrey Heller. 2017. Palestinian Authority halts payments for Israeli electricity to Gaza: Israel. [ONLINE] Available at: https://www.reuters.com/article/us-israel-palestinians-gaza-electricity-idUSKBN17T151. [Accessed 24 August 2018].

26. Tovah Lazaroff. 2017. Hamas Blames Abbas For Gaza Power Plant SHutdown. [ONLINE] Available at: https://www.jpost.com/Arab-Israeli-Conflict/Hamas-blames-PA-for-power-plant-shutdown-488201. [Accessed 24 August 2018].

27. Jack Khoury. 2018. Gaza’s Sole Power Station Closes, Residents to Have No Electricity for 18 Hours. [ONLINE] Available at: https://www.haaretz.com/middle-east-news/palestinians/.premium-gaza-to-lack-electricity-for-18-hours-a-day-after-power-plant-closes-1.6302170. [Accessed 24 August 2018]

28. Akbar Shahid Ahmed. 2015. Solar Panels Could Save Patients In Gaza’s Hospitals, Thanks To A New Fundraising Campaign. [ONLINE] Available at: https://www.huffingtonpost.ca/entry/gaza-hospitals-solar-power_n_7338188. [Accessed 24 August 2018]

29. Habar Merkezi. 2018. Solar panels installed in Gaza hospital. [ONLINE] Available at: https://www.yenisafak.com/en/video-gallery/news/solar-panels-installed-in-gaza-hospital-2195086. [Accessed 24 August 2018]

30. UnmahWelfareTrushUK. 2015. New Solar Power System at Essahaba Hospital in Gaza, Palestine. [ONLINE] Available at: https://www.youtube.com/watch?v=tvcnI0iU9Vk. [Accessed 24 August 2018].

31. Rami Almeghari. 2013. Gaza hospital chosen for solar power project. [ONLINE] Available at: https://electronicintifada.net/content/gaza-hospital-chosen-solar-power-project/12374. [Accessed 24 August 2018]

32. Linda McQuaig. 2018. Paying for solar panels for Gaza hospitals is not a big ask. [ONLINE] Available at: https://www.thestar.com/opinion/star-columnists/2018/07/04/paying-for-solar-panels-for-gaza-hospitals-is-not-a-big-ask.html. [Accessed 24 August 2018]

33. Qatar Red Crescent Society. 2018. QRCS Enhances Continuing Medical Education Capacity in Gaza. [ONLINE] Available at: https://reliefweb.int/report/occupied-palestinian-territory/qrcs-enhances-continuing-medical-education-capacity-gaza-enar. [Accessed 24 August 2018].

34. Palestinian Healthy Child Fellowship Program. Web page: http://my.sickkidsdonations.com/PersonalPage.aspx?registrationID=3838006&langPref=en-CA&Referrer=151786

35. State of Palestine, Ministry of Health. Personal Communication April 4 (2018).