“An Open-Air Graveyard”: The Unfolding Health Catastrophe in the Gaza Strip

It is impossible to count the number of reports, studies, press releases, and statements that have reported the unbearable conditions of life for Palestinians living in the Gaza Strip, especially since the beginning of the Israeli-imposed siege in 2007. Many efforts have comprehensively tracked and described food insecurity, poverty, maternal and infant mortality rates, water pollution, mental health, and myriad other issues. In 2012, a United Nations report estimated that based on a holistic assessment of living conditions in Gaza and predicted trendlines, Gaza would be “unlivable” by 2020.

Eleven years after the publication of this report, which was meant to serve as a warning, the world is not just witnessing, but enabling the situation in Gaza to go from an urgent crisis in what has widely been referred to as an “open-air prison,” to an utter human-made catastrophe—an “open-air graveyard.”

After almost three weeks of near constant Israeli airstrikes in a small and densely populated territory—over 12,000 bombs have been dropped on Gaza, considerably exceeding the number of munitions the US used in an entire year in Afghanistan—the United Nations estimates that more than 7,000 Palestinians have been killed, including at least 2,900 children. Almost 20,000 have been injured, and countless hundreds remain trapped under the rubble. With Israel and allied countries seemingly preparing for a long war and being unwilling to discuss a potential ceasefire, it is likely that these numbers will continue to increase.

Palestinian lives are not threatened only by airstrikes or a potential ground invasion, but, increasingly, from the lack of food, water, fuel, electricity, sanitation, and health care.

Palestinian lives are not threatened only by airstrikes or a potential ground invasion, but, increasingly, from the lack of food, water, fuel, electricity, sanitation, and health care. As more homes, schools, and hospitals are damaged or destroyed, Palestinians have fewer places in which they can shelter and seek services. Fuel stores are nearly empty, rendering the remaining few functional generators—including those sustaining life-saving care at hospitals—mere days from shutting off. Additionally, the mental health trauma caused by the knowledge that nowhere in Gaza is truly safe—and no one is coming to the rescue—is unimaginable.

A Rapidly Intensifying Crisis

Long before October 7, Gaza was already in a state of humanitarian crisis. Almost two thirds of the population, 63 percent, was food insecure, and a similar proportion, 65 percent, were living in poverty. Almost all of the water in the aquifer was non-potable, and a nearly two decade blockade by Israel had caused significant barriers to health care access, including limits on the importation of medical goods and the ability of patients to leave Gaza for needed services. Gaza had also been subject to multiple rounds of Israeli bombings and invasions since the beginning 2009. These previous assaults damaged multiple health, water, and power facilities and killed many experienced health professionals. After each war, Gaza has lost this crucial human capital while its physical infrastructure is never fully rebuilt.

It thus did not take long for the first round of Israeli attacks this time around to cause catastrophic damage, along with the “complete siege” on Gaza ordered by the Israeli defense minister, which barred the entry of food, medicine, water, fuel, and other supplies as constant bombardment hit the strip. After weeks of supposed negotiations, Israel permitted the first entry of around 20 trucks through Egypt on October 21, which were followed in the next few days by several more small groups of truck deliveries. Despite repeated calls for sustained humanitarian access, Israel has tightly restricted the number of trucks despite the obvious increased needs. On October 27, for example, it only permitted ten trucks.

Notably, these trucks only included water, food, medicine, and a small number of medical supplies. They did not include fuel, the lack of which hospitals have warned will cause them to essentially shut down within days. For comparison, around 500 trucks used to enter Gaza per day before the war, 45 of which brought fuel. Importantly, Israel only permitted the distribution of these goods in the south, contrary to calls by the United Nations to allow unimpeded access to them.

These trends represent a rapid deterioration in the conditions in Gaza for those still left alive after the airstrikes. In the first stages of this war, most of Gaza’s residents were at greatest risk from these attacks, including when Israel called on more than one million people in the northern part of Gaza to evacuate to the south. Several of the routes people were told to take for evacuation were bombed nevertheless, leaving many afraid to leave their homes. Furthermore, Gaza’s largest hospital, al-Shifa, is located in the north, along with many others. Aside from the patients and providers at these facilities, many hundreds or thousands of families shelter at these facilities with the hope that they will be spared from bombing. The World Health Organization called the evacuation a “death sentence” for many of these vulnerable people.

Hospitals are receiving around one thousand new patients per day, in a health system with just 2,500 total hospital beds.

Indeed, airstrikes are killing hundreds of Palestinians per day and injuring thousands more. Hospitals are receiving around one thousand new patients per day, in a health system with just 2,500 total hospital beds. Within days, hospital wards were full, with patients squeezing in on floors, in hallways and courtyards, and under stairs. Medical supplies are running out; systems are shutting down. Doctors are no longer able to sterilize tools. After bombings, they have started to make impossible decisions about which patients to admit and which have a lower chance of survival and would thus be left outside.

Reports of draconian conditions have emerged, with doctors performing surgeries with no anesthesia and with only the light of cell phones, using sewing needles instead of surgical ones, and using vinegar in place of antiseptic. Eventually, even the vinegar ran out. Undoubtedly, many trauma patients who may have survived will die due to these conditions; others will suffer unnecessary amputations and other debilitating and avoidable outcomes.

Conditions have now arrived at a point where aside from the wanton destruction of the airstrikes, lack of access to basic health needs will result in a sharp increase of mortality. As clean water becomes scarce and as sanitation services stop functioning, the risk for infectious diseases increases exponentially. This becomes a significant threat to civilians who have survived the Israeli strikes, especially as the number of safe places to take shelter decreases and available shelters get overcrowded. Health experts have already warned of the high potential for dysentery and cholera, which can lead to death very quickly, especially in children. With the overwhelming strain on the health system, facilities will have little capacity to manage such cases, especially if health workers themselves become afflicted.

As the remaining bakeries and markets are bombed, and supplies of flour are depleted, there is also an emerging fear of starvation among Gaza’s residents. Only one flour mill remains functional, and residents line up in bread lines for hours despite their fear of attacks. Adults have started skipping meals to feed their children, and even families who are able to receive a meal distributed from an aid agency are often sharing it with multiple other family members, and it may be the only food they have for the day. Oxfam International released a statement declaring what many had been warning about for weeks: “Starvation is being used as a weapon of war against Gaza civilians.” Meanwhile, truckloads of food are awaiting Israeli approval at the Rafah border, just miles away.

With Only one flour mill  functional, adults have started skipping meals to feed their children.

As the bombing directly threatens life and actively deteriorates social determinants of health, other health needs remain urgent. The UN estimates that there are around 9,000 cancer patients in the Gaza Strip, many of whom are undergoing chemotherapy at the enclave’s one dedicated cancer hospital. That hospital already had to stop radiology services to save electricity for the intensive care unit. Soon, even these services will be impossible to provide once the last generator runs out of fuel. Before October 7, and due to the limitations of the pre-existing Israeli siege, many Gaza cancer patients would apply for medical permits to access needed care in Israel or the West Bank. Gazans with other ailments sought care there as well. With Gaza completely sealed, all patients have completely lost their access to time sensitive, vital care.

Gaza already reports high rates of infant and maternal mortality, even when compared to Palestinians in the West Bank. Today, an estimated 50,000 women in Gaza are pregnant, with at least 5,000 due to give birth within the month. An untold number of these women will suffer from complications from pregnancy or birth, putting the lives of the mother or the child at risk, yet will not have access to the services that could save their lives. Already, women who can make it to a hospital to give birth are being asked to leave almost immediately to save space for the injured, forcing them to miss out on important recovery time. Furthermore, at least 130 premature babies are in incubators across Gaza and are at risk of immediate death once the equipment stops functioning.

As it has with all previous assaults on Gaza, Israel has caused significant damage to medical infrastructure. At least 43 health workers have been killed, and those working pull 24-hour shifts, without being able to go home for days on end in order to keep up with the constant influx of patients. At the time of writing, an estimated 12 hospitals and 32 other health facilities are out of service due to damage from bombing or lack of fuel, and multiple ambulances have been destroyed. As the last supplies of fuel run out, doctors are warning that hospitals will “become a mass grave.”

Needless to say, the psychological toll of this unending trauma and insecurity is nearly impossible to measure. Tens of thousands of Gazans have lost loved ones and doctors have begun to specifically identify “wounded children with no surviving family,” adding hundreds to the many hundreds of orphans in Gaza. Hundreds, if not thousands, have survived after being trapped under rubble for hours; others have simply sat night after night, huddled with family, hearing the constant sound of bombing nearby and jets overhead. They live with the constant fear of not knowing if they will be next; if they are safe enough to make a trip to the bakery; if they should sleep in the same room, so they can die together, or split apart, so members of the family can potentially survive if the home is bombed. Parents have started writing their children’s names on their body so they can be identified if they are bombed. The airstrikes could end tomorrow, and these people’s lives have been irrevocably changed for the worse in ways medical terminology cannot even begin to describe. If they are lucky enough to survive the current bombings and remain in Gaza, they are unlikely to be able to access the mental health services required to process such trauma due to lack of capacity.

What Does the Future Hold?

Israel has promised a long and punishing assault on Gaza, and current levels of Palestinian death, destruction, and dehumanization far surpass what had been witnessed in all previous bombings of the enclave combined. Israel has also made its territorial aspirations clear, as the country’s foreign minister recently said that after the war, “not only will Hamas no longer be in Gaza, but the territory of Gaza will also decrease.” Almost half of the homes in Gaza are already destroyed, and the world powers have only begun hinting at a potential “humanitarian pause” of military action but seem to be showing no urgency despite the desperate pleas of Gaza’s residents. There does not seem to be any going back to normal for Gaza, even when the enclave’s definition of normal was an unacceptable standard by any measure. This time around, it seems that Israel wants to realize the UN’s 2012 prediction that Gaza would indeed be unlivable.

The brave and tireless health workers who have thus far survived have told the world that the health system of Gaza is collapsing or has essentially collapsed. At the same time, the global powers have offered full-throated military, economic, and political support for Israel. The president of the United States has even cast doubt on the death toll released by Palestinian health authorities in Gaza. Aside from enabling mass death, trauma, and destruction in Gaza, the consequences of the world’s complete disavowal of the principles of human rights, of rules of war, and of showing any semblance of humanity when it comes to Palestinians will echo far and into the future.

Despite this dismal assessment of the current situation, the humanitarian crisis in Gaza thus far pales in comparison with the potential threats to health that are going to accelerate as conditions worsen and supplies finally run out. At this point, every major humanitarian agency has said that nothing less than an immediate ceasefire and the assurance of safe and sustained access to water, food, health care, and fuel was required to prevent the “catastrophic” situation from deteriorating further. Indeed, in the words of the World Health Organization, “The world must do more.”

The views expressed in this publication are the author’s own and do not necessarily reflect the position of Arab Center Washington DC, its staff, or its Board of Directors.

Featured image credit: Shutterstock/Anas Mohammed