The Lancet : Battling COVID-19 in the occupied Palestinian territory

Published in the Lancet September, 2020

The outbreak of coronavirus disease 2019 (COVID-19) in the occupied Palestinian territories, and Gaza specifically, highlights the effect of an ongoing blockade on public health. In 2007, following Hamas’s takeover, Israel and Egypt imposed a land, air, and sea blockade of Gaza. According to Israel’s cabinet decision at the time, Gaza was declared as being governed by a “hostile entity” due to Hamas’s attacks on Israeli citizens. The blockade included prohibitions on what is known as dual use materials (that can be used for both civilian and military purposes). However, the prohibition includes items that have nothing to do with security—eg, certain kinds of food—and others that were aimed as punishment—such as electricity limitations. The extensive nature of the blockade has had a devastating impact on the health and wellbeing of residents in Gaza.

As of June 30, 2020, a total of 2443 cases of COVID-19 have been diagnosed in the occupied Palestinian territory, 72 of which have been in Gaza.[[WHO,
Coronavirus disease 2019 (COVID-19) situation report 27.]] The Palestinian Ministries of Health in both Gaza and Ramallah have acknowledged that their capacity to contain the spread of COVID-19 is limited by ongoing and pre-existing shortages in health-care equipment, including medications and disposable equipment. Public health measures have erred on the side of caution and largely contributed to a very low infection rate during the first 3 months of the crisis; for example, Gaza has recommended that individuals returning from outside Gaza through the Rafah or Erez crossing remain in quarantine for 21 days, instead of 14 days.[[Palestinian National Authority Ministry of Health Unit of Information System, Daily report for COVID 19 virus.]]

Yet these efforts are hampered by the unique restrictions faced by the Palestinian health system. If even well equipped health-care systems in European countries have found handling this crisis difficult, then the Palestinian health-care service, which bears the burden of budget shortages and decades-long fragmentation, is likely to fare much worse. The separation between East Jerusalem, Gaza, and the West Bank, and the restrictions that Israel imposes on the freedom of movement of patients, medical equipment, and health-care personnel, structurally impedes the proper functioning of the Palestinian health-care system.

The blockade of 13 years means that many treatments in Gaza are unavailable and local health-care staff do not have up-to-date medical knowledge. As a result, more than 9000 patients need Israeli exit permits to leave the Gaza Strip each year for treatment that is unavailable locally, a quarter of whom are patients with cancer.[[WHO, Right to health 2018.]]

The insufficient amount of equipment needed to treat COVID-19 in the occupied Palestinian territory (eg, 87 intensive care unit beds with ventilators for nearly 2 million people and a paucity of personal protective equipment) is compounded by poor public health conditions: a water and electricity crisis, rampant poverty, and a high population density.[[WHO, Coronavirus disease (COVID-19) situation report 33.]]

Meanwhile, patients who need treatment that is unavailable locally face a dilemma: remain untreated or risk being infected with COVID-19 as they leave the Gaza Strip. Adding to this dilemma is the mandatory return to Gaza’s underequipped isolation centres, which places an additional risk on health. WHO estimates that, as of the end of March, there were around 1200 patients who need to leave Gaza for treatment, including dozens of patients with cancer.[[WHO, Health access. Barriers for patients in the occupied Palestinian territory.]]

Physicians for Human Rights Israel (PHRI, the health and human rights organisation where we both work) has demanded that Israel acts transparently and publishes the country’s policies on preventing an outbreak in the occupied Palestinian territory. The Geneva Convention requires the occupying power to take “prophylactic and preventive measures necessary to combat the spread of contagious diseases and epidemics”.[[International Committee of the Red Cross, Geneva convention relative to the protection of civilian persons in time of war (fourth Geneva convention).]] Although Israel has security concerns, the restrictions it has placed leave thousands without access to adequate care. There are encouraging initial indications that cooperation between Israel, the Palestinian Authority, and Hamas has taken place, at least indirectly. However, further steps must be taken.

To enable the Palestinian health systems to manage the outbreak, Israel must lift its closure of the Gaza Strip to enable the proper functioning of Gaza’s health-care system and other essential services in the face of the COVID-19 pandemic. Lifting of the closure must include removing barriers to the movement of goods. Where medication and equipment are unavailable because of budgetary shortages or arguments of dual use, Israel should help to ensure the supply of the missing materials to the greatest extent possible. Simultaneously, the Israeli authorities must work with Hamas and the Palestinian National Authority to find solutions for patients who currently cannot leave the Gaza Strip but must receive treatment unavailable therein.

PHRI filed a petition with Israel’s Supreme Court demanding the aforementioned aid. In its response on May 7, Israel detailed some of the very limited aid that has been provided thus far. Yet, given the aforementioned shortcomings in the health systems in Gaza and the West Bank and the extent of Israel’s responsibility, the aid it has provided thus far is largely symbolic. The petition has been withdrawn, but PHRI will continue to push for increased assistance to Gaza, especially in light of a potential second wave.
We declare no competing interests.