As the world has endured the crushing outcomes of the COVID-19 pandemic over the past seven months, a common refrain often heard is that “the virus knows no borders.” This airborne respiratory illness that appears to spread more easily than some of its well-known coronavirus predecessors, including severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), has made clear that as long as humans maintain some level of social interaction, COVID-19 will be a fixture in our lives until a vaccine can reduce or eliminate its spread.
It is essential to consider how the virus operates in an environment that has no defined borders yet features some of the most restricted movement in the world.
It becomes essential to consider, then, how the virus operates in an environment that has no defined borders, at the same time, features some of the most restricted movement in the world: the Occupied Palestinian Territories (OPT), comprised of the West Bank, East Jerusalem, and the Gaza Strip. The state of COVID-19 in the OPT has been put in especially stark relief as of late October 2020, as top Palestinian official Saeb Erekat remained hospitalized in critical condition after contracting the virus, following news of PLO Executive Committee member Hanan Ashrawi’s COVID-19 diagnosis. Two other senior Palestinian officials, Azzam al-Ahmad and Ahmed Majdalani, reported positive tests in late October, along with Saleh al-Arouri, a Hamas leader in Gaza. The rapidly growing list of Palestinian leaders who have contracted the virus this far into the pandemic reflects the overall trajectory of the virus in the OPT.
Differences between these territories in governance, infrastructure, and the preexisting health of their populations have led to three distinct case studies of how social and political determinants of health are expressed in a pandemic setting.
This analysis examines the COVID-19 crisis in the OPT, assessing the course of the virus throughout each of the three fragmented territories. The scope of this analysis excludes the Arab Palestinian population living in Israel, Palestinian prisoners in Israeli jails, and Palestinian refugees outside the territories, all of whom are experiencing significant hardship under COVID-19; nevertheless, their fortunes are closely tied to their brothers and sisters living in the OPT. Differences between these territories in governance, infrastructure, and the preexisting health of their populations have led to three distinct case studies of how social and political determinants of health are expressed in a pandemic setting. What the territories do have in common are the Israeli occupation and an emergent wave of virus cases in the fall of 2020 and what now appears to be uncontrolled community spread.
The Gaza Strip
Because of its unique situation of almost complete isolation due to a nearly 15-year siege and blockade, Gaza’s ability—or lack thereof—to manage COVID-19 is unlike any other environment in the world. Surrounded by Israel to the north and east, Egypt in the south, and the Mediterranean Sea to the west, Gaza has only two entry/exit points for its population: the Rafah Crossing, controlled by Egypt and almost always closed, and the Erez Crossing, strictly regulated by Israel. As we have learned, controlling the movement of people is fundamental to controlling the spread of the virus. Thus, Gaza did not see its first cases until late March, identified in two men returning to Gaza from Pakistan who were immediately isolated in a hospital in Rafah. Hamas, the governing body in the Strip, was well aware that an outbreak in the territory would be overwhelming to its already depleted and inadequate health care system. It immediately imposed strict quarantine procedures and community lockdowns, including shuttering wedding halls and markets, which make up a significant part of the summer economy. For most of the season, Gaza was able to maintain a low infection rate, with no days surpassing 20 new cases, and very few deaths. The first death, of an elderly woman, occurred as late as May 23rd. Despite concerns about the lack of ventilators, intensive care unit capacity, and testing kits, there seemed to be some hope that Gaza could avoid some of the potential worst-case scenarios using strict population controls.
It was only a matter of time, however, before the confluence of factors that have rendered the Gaza Strip nearly “unlivable,” as defined by the United Nations, would shatter this relative calm. Gaza is an incredibly dense and entirely urban environment where social distancing is impossible. There is a lack of safe and clean water, sanitation and hygiene access is inadequate, and electricity is limited in most facilities, including hospitals, to less than four hours per day. While the Gaza Strip had long been low on testing kits, this was manageable while community spread was minimal. However, gaps in testing residents reentering Gaza through Egypt or Israel meant that community transmission was inevitable. While Israel provided some testing kits and international donors, including the World Health Organization, provided thousands more, the massive need for testing meant that supplies lasted for mere days.
It was only a matter of time, however, before the confluence of factors that have rendered the Gaza Strip nearly “unlivable,” would shatter this relative calm.
In May, the most severe lockdowns lifted, giving an artificial sense of normalcy. Undetected cases not only reentered the population but were then allowed to mix with others at public spaces and private gatherings. By early September, the infection rate rocketed from 2 or 3 new cases per day to nearly 100. Officials called for a second lockdown, closing schools and mosques. In late September, health officials in the Strip reported a 65 percent shortage in blood bank and laboratory supplies, a 47 percent shortage in medications, and a 33 percent shortage in medical supplies. The shortages meant that one of the two devices that medical staff used to analyze tests was non-operational, further limiting their capacity to test, track, and isolate. By this time, the economy was even worse than its already poor pre-pandemic baseline. Poverty and food insecurity were on the rise as unemployment ticked up along with COVID-19 infections, with reports that some people were digging in the garbage to look for food. By October 23rdthe Ministry of Health in Gaza had documented more than 5,000 cumulative cases, including nearly 2,000 active cases, and 30 deaths. The mounting economic desperation had other unfortunate effects on mortality: reports of suicides and attempted suicides in Gaza, especially among unemployed young adults, have increased as the seemingly hopeless situation continues to unfold.
The West Bank
While residents of the West Bank suffer from daily movement restrictions under the Israeli occupation, the artificial borders of the small, fragmented territory—delimited by Jordan and the Dead Sea to its east and otherwise encompassed by Israel—are significantly more porous than in Gaza. Thus, it is not surprising that the first cases of COVID-19 were reported in the West Bank weeks before it was detected in Gaza. Seven cases were identified in a group of Greek tourists visiting Bethlehem on March 5th; as they were immediately isolated and the first lockdown measures in the West Bank took hold, closing tourist sites, schools, mosques, and churches in Bethlehem and cancelling large gatherings and events.
Shtayyeh’s quick calls for lockdowns, deployment of Palestinian police to erect roadblocks and enforce curfews, and overall transparency and responsiveness earned him high marks from the Palestinian public as well as international entities.
Initially, Palestinian Authority (PA) Prime Minister Mohammad Shtayyeh’s handling of the pandemic was widely praised. While President Mahmoud Abbas’s approval rating has been steadily declining as he enters his 15th year of a four-year term (and 62 percent of the public calls for his resignation), he was essentially invisible as the pandemic entered the West Bank. Instead, Shtayyeh’s quick calls for lockdowns, deployment of Palestinian police to erect roadblocks and enforce curfews, and overall transparency and responsiveness earned him high marks from the Palestinian public as well as international entities. Throughout April and May, only a maximum of 10-20 new cases were reported per day, on average, and very few people died. The West Bank has one major entry/exit point for the Palestinian population: the Allenby Bridge (or the King Hussein Bridge) to Jordan. For its part, Jordan moved quickly to limit crossings and, as visits from foreigners essentially halted, the only entrants to the West Bank were those Palestinians returning home, and they were told to isolate. Community transmission was further contained with improvised PA inspection points to ensure adherence to curfews and to check on the health of travelers. Although such measures mirrored the preexisting regime of movement restrictions, Palestinians largely understood the limitations of the health care system if an uncontained outbreak occurred in the West Bank. In early April, up to 96 percent of Palestinians in the West Bank approved of the strict movement restrictions. Like Gaza, however, the lockdowns were devastating to the West Bank economy; the World Bank estimates that the pandemic will easily shave off up to 7 percent of GDP, and likely more, depending on the secondary economic effects.
As cases in Bethlehem began to rise, the first cases not related to the initial tourist cluster started to be reported throughout the West Bank, initially in Tulkarem. They were discovered in laborers working in Israel whose employer had contracted the virus abroad. The first death in the West Bank, a 60-year-old woman, came in late March. She was thought to have contracted the virus through her adult children who worked in Israel. These initial cases demonstrated one of the primary weaknesses in the movement controls instituted by Palestinians. Unlike in Gaza, Palestinians from the West Bank cross into Israel regularly for work, usually in construction. While nearly 130,000 of these laborers are estimated to have work permits, many more find ways to enter Israel unofficially. As unemployment is high in the West Bank due to the impact of the decades-long occupation, and construction in Israel is highly dependent on Palestinian labor, projects have continued and work on them has even accelerated. The Israeli government issued stay permits for some workers to reduce cross-border travel, but reports of poor living and working conditions led to a petition by several NGOs to ensure the improvement of standards for Palestinian workers during the pandemic.
Another opportunity for virus transmission comes with the presence of Israeli soldiers in the West Bank, including at Israeli military checkpoints and during raids into Palestinian homes and home demolitions.
Along with the passage of Palestinians into Israel for work, another opportunity for virus transmission comes with the presence of Israeli soldiers in the West Bank, including at Israeli military checkpoints, during raids and incursions into Palestinian homes and in the course of home demolitions. Palestinians accused Israeli soldiers of purposefully trying to spread the virus, including by continuing to enter Palestinian homes despite outbreaks within the ranks of the Israeli military, and dumping used masks in Palestinian towns. Although the first cases of COVID-19 were detected in Israel in late February, demolitions of dozens of homes and other structures, including water and hygiene facilities and tentsmeant to be used as field clinics, persisted throughout March, making more than 60 Palestinians homeless. In April, in response to criticism about such practices during a pandemic, Israeli authorities committed to halting demolitions of populated buildings. Yet data show that demolitions have continued, including those that displace residents. Israeli forces have also removed Palestinian Authority inspection points erected to minimize virus spread and were accused of demolishing a building in Hebron meant to be used as a testing center.
By mid-October, the West Bank had reported more than 50,000 positive cases and approximately 500 deaths. The epicenter of the virus appears to be in Hebron, which has reported more than 17,000 cases—significantly more than any other governorate. Almost half of all coronavirus-related deaths in the West Bank originated in Hebron. While Hebron’s size and its position as a commercial hub might explain some of these exceptionally high numbers, Palestinians also reason that the tight-knit nature of Hebron’s clans and families plays a role. As one Palestinian health official said, “Social relations in Hebron are different from [those in] other Palestinian cities. At a single wedding or funeral you might find 1,500 or even 2,000 people.” As was seen within Gaza, low initial cases in the spring led to a sense of security within the West Bank, and social gatherings like weddings and funerals increased in the summer. Hebron is also the home of tens of thousands of Palestinian workers who travel to Israel; in addition, residents of the Negev and Palestinians from Jerusalem visit the city frequently. Due to these and other factors, Hebron is a microcosm of many of the problems plaguing the West Bank as a whole. It is also divided into different areas of administration, so although the PA instituted new lockdowns in the areas it controls, Israel did not do so in the sectors under its jurisdiction. Movement between the sectors led to clear paths for contagion spread.
East Jerusalem’s plight is wholly unique, incorporating challenges similar to both Gaza and the West Bank as well as a host of novel difficulties. East Jerusalem is geographically linked to the West Bank, lying on the edge of the territory’s western border with Israel. However, East Jerusalem is not only off limits to Palestinians from Gaza but is also highly inaccessible for Palestinians from the West Bank. Because this area was annexed by Israel in 1967, Palestinians in East Jerusalem are not administered by the PA, yet most are Israeli residents and not citizens. They pay municipal taxes but receive few public services; indeed, infrastructure is poor and the provision of water and sanitation utilities is lacking. As a result, 77 percent of residents live below the poverty line. Entire families may reside in a dwelling with just one or two rooms.
East Jerusalem’s plight is wholly unique, incorporating challenges similar to both Gaza and the West Bank as well as a host of novel difficulties due to the administrative gap.
This administrative gap was immediately apparent at the onset of the pandemic; human rights groups have had to petition Israeli authorities to open testing facilities, provide Arabic-language health materials, and fill other disparities in areas of employment, education, and health promotion. When Palestinian officials attempted to build their own testing centers to fill some of these gaps, they were shut down and their organizers were arrested by Israeli forces. Like the other isolated Palestinian territories, these deficiencies were manageable as initial caseloads remained low throughout the spring. By late April, only 151 cases were confirmed (in part due to limited testing) and there were only two deaths, the first on April 18. Jerusalem officials, who have a contentious relationship with the local Palestinian population, received initial praise for their coordination efforts; however, as initial lockdowns relaxed, coordination efforts also faltered. As with Gaza, density made social distancing difficult. Gatherings increased as residents began to doubt the severity of the virus, even for those who had tested positive or had been exposed. Testing centers that had opened in the first wave did not reopen, even as cases increased, and bottlenecks at the remaining facilities discouraged testing. Weddings and other celebrations persisted and were not monitored by Israeli police, while Palestinian security officials who were tasked with enforcing shutdowns and limiting crowds were denied access. Further, when cases were detected, it was unclear who should take responsibility. In areas like Kafr Aqab (outside the separation wall but within Jerusalem’s authority), Israel’s health ministry refused to allow infected patients to quarantine in Israel and they had to be taken to Ramallah. Ironically, weeks later, Israeli officials put up a northern military checkpoint specifically to prevent travel to Ramallah.
Testing centers that had opened in the first wave did not reopen and bottlenecks at the remaining facilities discouraged testing, while Palestinian security officials who were tasked with enforcing shutdowns and limiting crowds were denied access.
As in the West Bank, home demolitions in East Jerusalem persisted and even increased during the pandemic. By late October, more than 141 structures had been demolished and over 350 Palestinians displaced. Along with demolitions, political maneuvers did not stop either. In response to threats of impending annexation in the West Bank, the PA ceased security coordination with Israel in the spring. Tangibly, this meant that patients from Gaza and the West Bank who needed advanced care, which was usually accessible to them in East Jerusalem, could no longer apply for the permits they needed to travel there. The loss of these patients and of the payments for their care from the Palestinian Ministry of Health put the hospitals in dire financial straits right as the pandemic was hitting. This meant that the hospitals were no longer able to adequately serve the local underprivileged populations who could not pay for care. These hospitals are also poorly resourced for ailments like COVID-19 that, for high risk patients, require long-term intensive treatments. The resources of the six main East Jerusalem hospitals—especially after the massive funding cuts of the Trump Administration in 2018—were drastically reduced, and between them there were only about 20 ventilators. Donations from religious and other private organizations bolstered some supplies, but the pressure on the local medical and administrative staff, many of whom live in the West Bank and could not return home, was intense. By mid-October, East Jerusalem had reported 11,341 cases and 70 deaths—remarkable, given the area’s small size.
Addressing Injustice Is a Health Priority
Sumud is a concept long associated with the Palestinian story. This Arabic word loosely translates as steadfastness or resilience; it is a way that Palestinians frame their struggle against more than a century of colonialism, war, and occupation. In terms of health, this is a refreshing way to look at positive aspects of Palestinian well-being outside of dehumanizing mortality and injury counts. However, as renowned Palestinian public health expert Rita Giacaman argues, “All too often, Palestinian ‘resilience’ is over-rated and sometimes used as a means of avoiding acknowledging and addressing the issue of injustice.” The baseline environment in which COVID-19 entered the fragmented Palestinian territories was already experiencing a series of humanitarian crises, supported by well-meaning but inconsistent foreign aid, which made up 32 percent of Palestinian GDP in 2008 but only 3.5 percent in 2019. In the current period of the pandemic, Palestinian resilience is not sufficient to counter what is a true public health crisis that has strained the world’s richest and most stable states.
The baseline environment in which COVID-19 entered the fragmented Palestinian territories was already experiencing a series of humanitarian crises.
During October 1-15, new cases throughout the OPT averaged 460 per day, with 471 cumulative deaths. The spread of COVID-19 in Palestine has clearly been exacerbated by the preexisting social, political, and economic weaknesses of the territories. Palestinian efforts to implement physical distancing were stymied in the West Bank and East Jerusalem; further, severe isolation did not protect Gaza from a community outbreak. Lack of testing capacity likely hid the true number of cases, and although mortality remains low, hospitals that were already struggling—largely due to the Israeli occupation—to meet the population’s needs are now being crushed by the demand for coronavirus-related health services. Routine medical procedures and vaccinations have been delayed, further threatening public health. For example, it is estimated that more than 1,200 time-sensitive eye surgerieshave had to be cancelled. The Palestinian economy, on a steady decline after being artificially propped up by massive foreign aid investment following the second intifada in the early 2000s, is being battered by the local and global instability of the pandemic. With Palestinians constituting the youngest population in the region (people above age 65 make up less than 3 percent of the Palestinian population), this has had some protective effects when it comes to reducing COVID-19 mortality. However, a dependence on luck, goodwill, and resilience is not a sustainable health intervention.
Dependence on luck, goodwill, and resilience is not a sustainable health intervention. Social, economic, and health indicators cannot meaningfully improve within the context of siege and occupation
What has been clear to Palestinians for decades is now hopefully evident to the rest of the international community, including Israel: that social, economic, and health indicators cannot meaningfully improve within the context of siege and occupation. While the Palestinian population would have undoubtedly had to deal with the onset of COVID-19 regardless of their political situation, their ability to make autonomous decisions with the requisite resources has been significantly reduced by their constrained sovereignty. Despite its legal obligation as an occupying power to protect Palestinians in the OPT, Israel has shirked this responsibility and continues to flagrantly neglect this requirement to use its resources for protecting the Palestinians from COVID-19. Moreover, international pressure has been ineffective in enforcing Israel’s responsibility to fully support the health needs of the Palestinian population under its control, especially in a time of significant global shocks. As we move to think about a post-COVID-19 reality, it becomes increasingly difficult to defend the structures of occupation, and armed conflict more broadly. Only when all people, including the Palestinians, are afforded the human rights that foster strong societies can we ensure true global resilience for the next health crisis.