The Israeli military operation, 'Cast Lead', was launched in the Gaza Strip on 27th December, 2008.
Franck Joncret, MSF head of mission in the Palestinian Occupied Territories, provides an update on the current situation in the Gaza Strip and MSF's response.
What is the situation in the Gaza Strip – in terms of health and in general – now that the war is over?
Before the war, the hospitals in the Gaza Strip were already operating in full emergency mode. 'Cast Lead' pushed them into a crisis situation. Throughout the war, the Shifa hospital was the referral healthcare facility and the destination for most ambulances. Its six operating rooms operated at full capacity, around the clock. Hospital employees throughout the Gaza Strip were overwhelmed and exhausted but completely capable of handling the situation. Under the circumstances, however, all non-emergency procedures were postponed, meaning waiting lists for specialised surgery, such as plastic and orthopedic surgery for the war-wounded, are growing.
During the war, the Israeli authorities did not provide the security guarantees that humanitarian aid workers require in order to help civilians who were trapped and unable to flee. Hospitals, ambulances and International Committee of the Red Cross and UN convoys were caught in firing and/or bombing. The daily ceasefire was a unilateral decision by Israeli forces, which meant it wasn't a ceasefire. Every time the Palestinians fired a rocket, the Israeli Army retaliated. What’s more, the daily truce applied only in Gaza City and it was very difficult for the ambulances to reach wounded people in the surrounding areas. Added to this, and given the insecurity, many patients and wounded people whose condition was not critical were afraid to leave their homes.
For all those reasons, once the offensive ended, we decided to treat patients who'd been discharged too rapidly from overflowing hospitals or who could not be treated during the height of the crisis. As a result, we had lots of multiple injuries, fractures and severe wounds, along with people burned over large portions of their body and amputees, too. According to the Ministry of Health, there are hundreds of amputees and they require specific treatment. They must wait more than a year for a prosthetic.
The war caused extensive destruction. Buildings, houses and public facilities that were destroyed still bear witness to the violence of the Israeli offensive. The embargo, imposed on the Gaza Strip in 2006, prohibits the entry of a wide range of items, including all building materials and equipment. The situation is frozen and the piles of rubble remain. The blockade has been tightened twice – in October 2007 and again in January 2008 – and also severely restricts the entry of food and medical supplies. Only a quarter of food needs are covered (of the 400 trucks that would be necessary, only 100 are allowed to cross each day).
The Israeli operation did not spare healthcare facilities either. Two primary care centres were destroyed and two hospitals were damaged. The prohibition against building materials means that only partial rebuilding has been possible. After the war, there was a huge volume of donations but, unfortunately, little of that addressed the actual needs. As a result, the situation is the same today as it was before the war – with approximately 20% of essential medications lacking in the Gaza central pharmacy. Electricity is shut off every day and the hospitals are still required to use emergency generators. Given the destruction of the water system and only partial repairs, some 10,000 people (according to World Health Organisation estimates) lack water. We also have serious concerns about the quality and health impact of the water that is provided.
The embargo’s humanitarian, human and economic impacts can be seen in access to medical care and the population’s general health status.
How did MSF respond?
The Gaza City post-operative care clinic has been working at full capacity since January 18. The Khan Yunis clinic, in the south, has reopened and the Beit Lahia pediatric clinic followed. On the 19th, all our facilities were operational and all MSF teams were at work. Our activities doubled and our typical 200-patient cohort rose to more than 400. By the end of May, we were treating 700 patients, post-operative care had increased by 60%, and we decided to open a third post-operative care clinic in Beit Lahia, in the north, an area that was particularly hard-hit during the war. We went from three mobile teams to seven so that we could treat patients unable or unwilling to travel, those living in sensitive areas, who feared for their safety and who lacked the material, physical or financial resources to travel. The level of post-operative care activity is just now starting to slow.
Regarding mental health, the psychology coordinator debriefed our Palestinian staff every day by phone during the war. A special phone number was set up for that purpose. Our post-war work is focused on certain populations that were very exposed, in psychological terms, such as ambulance drivers, firefighters, first aid workers, and doctors and nurses working in independent facilities and NGOs – those who put themselves in danger to save others and who had very difficult experiences and saw very painful things. Our Palestinian staff were also debriefed as a group for a month. At the same time, we continued our regular activities with patients who had been victims of violence resulting from the conflict. However, post-traumatic syndromes arise three to six months after the causal events and the numbers on the waiting list have grown exponentially. We've increased from two psychologists before the war to five – three Palestinian and two international staff – to meet the sharp increase in demand.
Initially, we thought we would set up our inflatable hospital and surgical tents within the perimeter of Shifa hospital. It was the reference facility, with more than 1,500 operations performed during the war. But we provided no added value there and preferred working in our own facilities in order to maintain our neutrality and impartiality. We found a piece of land, across from the MSF office, which was cleaned and leveled. After five days of set-up, we were able to work in the tents. That was 25th January. We started operating there the next day. We focused on non-critically wounded patients who had not been treated during the 'Cast Lead' campaign - patients who had been discharged and referred by Shifa for non-emergency and revision surgery. The idea was to ease the Gaza hospitals' responsibility for this kind of surgery, allowing them to resume scheduled surgery as that list had, obviously, grown during the war. Many of the wounded had been evacuated outside the country and plastic surgery began in March, when they returned. Treatments included wound debridement, skin and muscle grafts, removal of shell fragments and contracture release for burn victims. Today, we no longer perform plastic surgery in the tents and are working to set up a referral system to hospital facilities in the Gaza Strip for those 80 patients still on the waiting list for this, as well as for stump repairs, removal of internal and external fixators, bone grafts and osteosyntheses. From January - July 2009, we treated 362 patients and performed 518 surgeries - primarily surgery (80%) and orthopedic (16%).
Overall, at the end of the war, we had grown from 75 Palestinian employees to 126 and from four expatriate staff to around 20. Today, the numbers total 104 Palestinian staff and five expatriates.
What does the future look like for the Gaza Strip?
I am very pessimistic, politically speaking. I don't see any positive signs today. The internal conflict continues as Hamas and Fatah take different paths. The split between the West Bank and the Gaza Strip is worsening. For the population, the internal political situation in Gaza has been radicalised. Humanitarian organisations are under pressure from the authorities. Despite the fact that almost no rockets have been shot from Gaza into Israel since the end of the war, the Israeli authorities have not let up in the least. There has been no easing of the restriction on the movement of people or goods. With regard to access via Egypt, that's very sporadic and limited to specific populations, including patients, foreigners and people carrying Egyptian documents. The Egyptian authorities will agree to keeping Rafah open permanently only when the reconciliation process between Fatah and Hamas is complete.
In fact, nothing has really changed since the period before the Israeli military incursion. The isolation has even worsened. The Gaza population is cut off from the world. To survive, most families rely on the minimal local agricultural production that remains after the massive bombing. The only farming that survived was flowers and strawberries, but everything was destroyed over years of conflict and incursions. In any event, export is impossible today. The economic system is virtually non-existent. The banks have no money, employees are not being paid, 45% of the population is unemployed, 80% live below the poverty level and 75% are totally dependent on humanitarian aid. This impoverishment worsens every month as a result of the embargo.
And it's not just economic. In the area of health, for example, the Gaza Strip has good infrastructure. Unfortunately, despite basic training, the medical staff lack information, additional training and support for learning new techniques. I'm thinking of the newest surgical procedures - the young surgeons can't go abroad for training. If this embargo continues, it will affect the quality of medical care. And one can reasonably assume that mortality rates and life expectancy in Gaza will be affected quickly.
The movement of people and goods must resume, otherwise there is no future there.
Recap of MSF's activity during the war
"We launched MSF's initial support from Jerusalem to Shifa Hospital. We arranged to send burn kits and dressings there and to other hospitals in Gaza.
Nearly every day, our teams went to the hospitals to assess the needs and the situation. The operating rooms and intensive care units at Shifa were overflowing. We decided to send surgeons and necessary supplies, plus two hospital tents -- one to house two operating rooms and the other for 10 intensive care beds. Together, that constituted a 21-ton shipment from MSF's logistical base in Bordeaux.
Our response could not match the intensity of the conflict and its impacts, but we still contributed large amounts of medicines and supplies, particularly to sites that sheltered displaced persons. The MSF clinic in Gaza treated 20 to 50 wounded patients daily and the MSF paramedical staff treated 275 patients using on-site medical kits. That’s not insignificant when there is no longer any access to medical care."