The War on Health in Gaza

The War on Health in Gaza

The Israeli government is restricting access to food in Gaza at the same time as it is destroying healthcare infrastructure. Each process intensifies the lethal consequences of the other.

Last week, an Israeli drone killed seven aid workers in hunger-beset Gaza. The cars were marked with the organization World Central Kitchen’s logo and “travelled along a route preapproved and coordinated with the IDF,” according to Haaretz reporting. But the military unit charged with coordinating the convoy’s journey errantly believed there was a lone armed individual in the three-car-convoy, according to Haaretz’s source, and so sent a Hermes 450 Drone to hunt him. After the drone hit one car with a missile, some of the passengers escaped to the second car. Then it hit the second car. When passengers from the third car tried to evacuate some of the wounded, they were struck by a third missile that killed everyone still living. New reporting from the Telegraph casts the attack in an even more sinister light: one of the IDF officers dismissed for his role in the bombing signed an open letter in January calling for the Israeli government to “do everything in [its] power” to prevent the delivery of humanitarian supplies and the operation of hospitals in Gaza City.

The methodical elimination of the World Central Kitchen convoy occurred at a desperate moment in Gaza. Last month, the UN-backed Integrated Food Security Phase Classification predicted famine would arrive between mid-March and May, and while there are technical thresholds that must be met for formal declaration of famine, there is little doubt that large-scale hunger is already underway. In January, screenings of a sample of children under two years old in North Gaza found that 15.6 percent met criteria for acute malnutrition and almost 3 percent for severe acute malnutrition—an indicator of muscle wasting and risk of death based on arm circumference. By February, UNICEF reported that these proportions had almost doubled, to 31 percent and 4.5 percent, respectively. The situation has almost certainly deteriorated further. “First there was flour, until it ran out,” a fourteen-year-old boy named Yousef Tafesh told National Public Radio. “Then we could get wheat, and that ran out. Then corn kernels. Then we tried animal feed. Now my mom makes us a pudding with water and starch and we eat that.”

Centuries ago, famine was often primarily the consequence of crop failures, adverse climactic events, and other acts of nature. Today, it is never an accident when children like Yousef go hungry: famines are manmade, and this one is no exception. The killing of the World Central Kitchen workers, along with previous attacks on aid workers and facilities responsible for food delivery, have coincided with Israeli siege policies that have slowed the entry of food into Gaza, including limited entry points and arbitrary rejections of shipments. “If we want to achieve our war goals,” Israeli Prime Minister Benjamin Netanyahu bluntly admitted in January, as quoted by CNN, “we give the minimal aid.” Famine is the predictable consequence of brutal siege and relentless war on an impoverished and isolated territory. This campaign of starvation is part of a war on health waged by Israel’s government.

Following the brutal attacks of October 7, the Israeli government blocked the transportation of water and food into Gaza, which lacks an airport or major seaport. “I have ordered a complete siege on the Gaza Strip,” Defense Minister Yoav Gallant stated, as quoted by The Times of Israel. “There will be no electricity, no food, no fuel, everything is closed.” Or as former Israeli Prime Minister Naftali Bennett said to a Sky News anchor in October, “I’m not going to feed electricity or water to my enemies.” Water and food delivery did resume, but never to sufficient levels, in large part due to ongoing obstruction by Israeli authorities. “The main blockers,” British Foreign Secretary David Cameron asserted in a March 15 letter, “remain arbitrary denials by the Government of Israel and lengthy clearance procedures, including multiple screenings and narrow opening windows in daylight hours.” In early March, for instance, the World Food Programme announced that its efforts to deliver food to northern Gaza had been “largely unsuccessful” after its fourteen-truck food convoy “was turned back by the Israeli Defence Force after a three-hour wait at the Wadi Gaza checkpoint.” In the face of global outcry (and pressure from the Biden administration) following the World Central Kitchen bombing, Israel announced it would re-open the Erez crossing in the north and allow more delivery through the port of Ashdod in the south—pivots that flatly contradicted the government’s previous claims that it had not been impeding the flow of food. As of yesterday, however, no aid was flowing through either Erez or Ashdod.

The number of trucks crossing Gaza’s borders is only part of the story. Economist Amartya Sen famously argued that famines can occur even where there is no reduction in food supply at all due to a plunge in some civilians’ “entitlement” to food, such as the loss of means to purchase or access it. In the case of Gaza, multiple dynamics are at work. Food prices have soared as a consequence of scarcity—one story reported a ten-fold increase in the price of rice—at a time when people’s incomes have evaporated. Meanwhile, local food production has collapsed. A report from the organization Insecurity Insight details widespread attacks on food production and provision, including 119 Israeli strikes on farmland; seventeen bombings of bakeries; the widespread destruction of markets, fishing boats, and shops; and killings of farmers and fisherman. A satellite-based analysis in January found that about one-fifth of the arable land in Gaza has been damaged, and another study found that 42 percent of water facilities have “sustained infrastructure damage.”

Meanwhile, the infrastructure needed for food transportation and aid distribution has been devastated. After the destruction of the World Central Kitchen convoy, the organization paused further aid operations, even turning around a ship full of aid from Cyprus. The U.S.-based nonprofit American Near East Refugee (ANERA) followed suit, announcing a pause in its food delivery efforts in response to the attack. Reliance on these nonprofits is, in turn, at least in part the consequence of attacks on, and the defunding of, the organization chiefly responsible for aid relief in Palestine: the United Nations Relief and Works Agency (UNRWA). The group has seen 176 of its staff killed since the beginning of hostilities, and many of its facilities targeted by Israeli airstrikes. On February 5, Israeli forces attacked a UNRWA convoy that was “carrying vital food supplies in central Gaza,” according to CNN.  The following month, Israel blocked UNRWA from delivering aid to northern Gaza altogether. Around that time, Congress cut all funding to UNRWA, even as it continues to send giant numbers of bombs to the IDF. Overall, more than 200 national and international aid workers have been killed in Gaza thus far. Such violence—and the broader chaos and political vacuum unleashed by the war—mean that even when food gets into Gaza, it may not get to those who need it.

It will be some time before we know the full toll of the famine in Gaza—if we ever know it. There have been twenty-seven known deaths from malnutrition among children in Gaza at this time. But apart from difficulties in counting such mortality amid bombardment, the reality is that most deaths from malnutrition have infectious disease as the proximal cause, such as diarrheal illness among infants, which already appears epidemic: a survey conducted in January found a 70 percent rate of diarrhea in the preceding two weeks among children in Gaza. There is no neat disentanglement of deaths from starvation and disease, or from exposure, crowding, total lack of sanitation, and mass dislocation. In fact, famine death counts typically include all excess deaths, as scholar Alex de Waal explains in his book Mass Starvation: The History and Future of Famine:

…“elevated mortality” includes anyone who died, of any causes, above the baseline: it includes deaths from communicable diseases (often the single biggest cause of death), exposure and exhaustion, and in some instances, violence as well. Including all these deaths can be justified because famine is not just an aggregate of individual cases of starvation: it is a far-reaching social disruption that involves epidemics of infectious diseases, movements of desperate people, crime and an array of other social disorders.

The terrifying reality is that we have little idea how many “excess deaths” there have been in Gaza during this war. The reports of traumatic deaths, from bullets and bombs, are grim enough: more than 30,000 killed so far, and possibly far more. Yet when all is said and done, only overall excess deaths will tell us the full toll of the war on health. That figure, assuming we ever have it, will be devastating.

A second front on the war on health in Gaza has been the widespread destruction of healthcare infrastructure. Last month, the territory’s largest hospital—the 750-bed Al-Shifa Hospital—lay in ruins after a two-week-long assault by the Israeli military. The hospital had survived an earlier attack after the IDF claimed it was “the main headquarters for Hamas’ terrorist activity,” an assertion it supported with a notorious computer animation depicting a ludicrously labyrinthine subterranean lair. (What it actually found was militarily unimpressive.) Widespread reports of civilian deaths and patient harm have emerged at Al-Shifa after the latest and more devastating siege, although some details are still sketchy. The World Health Organization has stated that twenty-one patients died, and a physician at the hospital described sixteen deaths of intensive care unit patients to BBC; it is thus far unclear how many healthcare providers have been killed. In addition to the immediate death toll, the destruction of Al-Shifa will be devastating to healthcare delivery in the region. It also eliminates a place of refuge for uprooted Palestinians, as thousands sought sanctuary there amid the widespread destruction of homes.

A recent report from Doctors Without Borders—drawing on logbooks, testimonies, and other sources—describes a similar pattern of incessant strikes and assaults, including shelling and sniper attacks, on Nasser Hospital, which laid waste to its capacity to provide care. “Today there is no more hospital,” stated Leo Cans, the organization’s head of mission in the Palestinian territories. “It has been put to a full stop. No more electricity, no more water, no more medicines, and no more patients. The 700 patients have been forcibly evacuated.” Doctors Without Borders convoys have also been hit by Israeli forces, despite—like the World Central Kitchen—clear markings on their vehicles. Missile strikes have also killed doctors in their homes, ambulances have been targeted en route to hospitals, and healthcare workers and patients have been subjected to gunfire outside hospitals.

The scale and extent of damage suggests that Gaza’s healthcare facilities are an explicit target. This presumption is supported by a recently published geospatial analysis, led by researchers at the FXB Center for Health and Human Rights at Harvard, which analyzed radar-based satellite data and found high levels of damage to civilian infrastructure including health facilities, education, and water infrastructure—in excess of what would be expected from chance alone. Overall, they reported that 35 percent of health facilities in Gaza were “functionally destroyed” by November 22, 2023.

A total of at least 685 people have thus far been killed in attacks on healthcare facilities. Emergency medical transportation is basically no longer possible throughout northern Gaza. Only about 33 percent of the hospitals in Gaza and 28 percent of its primary healthcare facilities remain even partially functional at this moment of soaring health needs, hunger, and an epidemic of major trauma.

For millennia, hospitals have served as places of refuge; in Gaza today, they are increasingly places of ruin.

Similar to the impact of famine, there will be no easy accounting of the overall death toll from attacks on Gaza’s healthcare provision. Indeed, each process intensifies the lethal consequences of the other. The destruction of healthcare infrastructure undercuts the ability of Gazans to respond to famine, because these facilities are valuable in the emergency treatment of severe malnutrition; lack of access to care, conversely, will exacerbate susceptibility to the health impacts of food deprivation and infectious disease. The war on health in Gaza will have a long and deadly tail.

This crescendo of catastrophe can still be mitigated, although there is not a moment to lose. An immediate ceasefire and end to the war, a lifting of the siege, restoration of UNRWA funding, reconstruction of the healthcare system, and a massive increase in aid delivery to (and within) Gaza could help bring this war on health to a halt. The alternative—to hold the current course and let horrific famine take hold—is unthinkable, but without dramatic action it is also inevitable.

Adam Gaffney is a critical care physician, healthcare researcher, and assistant professor of medicine at Harvard Medical School.