Over the past year of a war without rules, Israeli forces have destroyed much of Gaza’s vital infrastructure–from its health services to water and sanitation systems. As a result, terrible living conditions are making people sick while medical services are harder and harder to access.
Doctors Without Borders/Médecins Sans Frontières (MSF) has worked in Palestine for 40 years and has witnessed how an air and sea blockade imposed by Israeli authorities on Gaza since 2007 presented significant challenges to the health care system by creating critical shortages of medical supplies. Despite the blockade, before the war the Gaza Strip managed to maintain a robust and functional health care system, including advanced surgical care, research, and stewardship on antimicrobial resistance, among other critical medical needs. Today, that health care system no longer exists due to the bombardment of health facilities by Israeli forces, dire shortages of vital supplies, and evacuation orders forcing patients and staff into life-threatening situations. Each time a medical facility is evacuated or attacked, people lose access to lifesaving medical care.
What does Gaza’s health care system look like now?
As of November 5, a mere 17 of Gaza’s 36 hospitals remain functional, and only partially so, according to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Eleven field hospitals (five fully functioning and six partially functioning) are operating, but they are meant to be a support measure and cannot replace the health system that has been destroyed. Only 36 percent of primary health centers are functioning, and 130 ambulances have been damaged.
At present, there are more than 100,000 wounded people in Gaza, of whom OCHA estimates 14,000 require medical evacuation for specialized care unavailable in Gaza. In addition, almost 60 percent of requests for medical evacuations from Gaza are turned down, according to the World Health Organization. Since Israel closed the Rafah border crossing in May—the main crossing point for supplies and people—only 229 patients have been evacuated, OCHA reports.
How does constant displacement impact access to care?
An estimated 1.9 million Palestinians (90 percent of the Gazan population) have been displaced over the past year by bombing and evacuation orders, most multiple times. Although there is no safe place in Gaza, successive evacuation orders have pushed more and more people into the tiny area of Al-Mawasi, where as of August there were 30,000 to 34,000 people per square kilometer [almost 78,000 per square mile.] People often have to wait in line for hours for water and even latrines, and are unable to regularly shower.
In addition to the destruction or closures of once-functioning hospitals, the decimation of infrastructure has created severe obstacles for pregnant women trying to access care due to hospitals being overwhelmed with casualties and the dangers of trying to reach medical facilities. Pregnant women are often forced to navigate unsafe routes amid the fighting and without safe transportation; some end up giving birth in tents or public facilities. The lack of access to prenatal health care puts them at higher risk of complications at a time when care options for complications is limited.
Burned-out health workers juggling overwhelming workloads
Amid constant bombings and evacuation orders, Palestinian health care workers, including MSF staff, have been risking their lives to provide medical care. They have been forced to amputate limbs without anesthesia, treat mass crush and burn injuries with extremely limited supplies, and try to work as Israeli forces have repeatedly besieged hospitals like Nasser and Al-Shifa.
Throughout the war, MSF has witnessed patients dying on hospital floors, as hospitals have been unable to cope with the overwhelming number of patients. In June, following intense bombings by Israeli forces in the Middle Area of Gaza, MSF teams treated an overwhelming number of severely injured patients at Al-Aqsa and Nasser hospitals. MSF Medical Referent Karin Huster described “kids completely grey or white from the shock, burnt, screaming for their parents. Many of them are not screaming because they are in shock.”
Dr. Javid Abdelmoneim, who worked as an MSF medical team leader at Nasser hospital, described the scene of a mass casualty incident in July. “In the emergency department, there was blood everywhere and I had to kneel to see the patients on the floor. Patients were sprawled everywhere, because there were no beds left. I could feel my knees getting wet from the blood.”
Attacks on health care facilities and staff
Over the past year, MSF staff have been forced to leave or evacuate from 14 health structures.
In November 2023, bullets were fired into one of three MSF premises located near Al-Shifa hospital. MSF staff members and their families had been sheltering there for safety amid the intense bombardment. MSF was forced to evacuate Al-Shifa hospital in November following the massive bombardment by Israeli forces, though staff members were able to visit the hospital in January and March. Medical workers were able to provide some services at Al-Shifa hospital until late March, when a 14-day long operation by Israeli forces in and around the facility reduced it to ruins.
On February 13, an Israeli military bulldozer destroyed the north gate of Nasser Hospital and ordered displaced people to leave. Medical staff and patients were told they may remain in the hospital with a limit of one caretaker per patient, but the next day an Israeli shell hit the orthopedic ward, killing one person and wounding eight others. Israeli forces ordered everyone inside Nasser hospital to evacuate and then stormed the hospital early in the morning on February 15. In the days following, patients were evacuated in small groups to several nearby field hospitals. On February 22, the Israeli army withdrew from Nasser hospital and left it severely damaged and unable to function.
As of mid-October, there were more than 500 recorded attacks on health care, including the targeting of an MSF convoy in late November.
How MSF is supporting health care in Gaza
Since the beginning of the war, MSF has offered surgical support, wound care, physiotherapy, maternity and pediatric care, primary health care, vaccination, and mental health services in the hospitals, clinics, and other facilities where we work throughout Gaza. Continuous sieges and evacuation orders on various hospitals, however, are pushing our activities into an ever-smaller territory and limiting our response.
MSF is supporting several hospitals, field hospitals, and health posts across the Gaza Strip. In late August, MSF opened a field hospital in Deir al-Balah—ahead of schedule to support Al-Aqsa hospital that was caught in a renewed wave of conflict and violence at the time. Field hospitals are not a solution, but a last resort in response to Israel’s dismantling of the health care system. Without hospitals like Al-Aqsa and Nasser in Khan Younis, field hospitals will struggle to cope with the urgency and abundance of medical needs.
Shortages of supplies directly impact the effectiveness of existing infrastructure
Without reliable access to fuel and medical supplies, the small portion of Gaza’s surviving health care system cannot operate: with no electricity available in the strip, hospitals rely on fuel-powered generators to use lights, operating rooms, ventilators, and other essential equipment.
MSF teams have witnessed increased blockades, obstruction, and unjustifiable delays in the transport of medical supplies and equipment our patients need for treatment since October 2023.
The closure of the Rafah crossing in May, which was a main point of entry for aid and an exit for medical evacuation, has made it extremely difficult to obtain necessary supplies.
Today, the vast number of border crossings remain closed with only a trickle of aid entering Gaza.
What is the state of water and sanitation infrastructure in Gaza?
According to OCHA, water production in the Gaza strip is only at 25 percent compared to levels pre-October 2023. Also, two of the three desalination plants are only intermittently operational. In displacement shelters, the average space per person is 1.5 square meters, much lower than the minimum emergency shelter indicator of 3.5 square meters.
OCHA estimates that 395,000 tons of solid waste have accumulated, and two central landfills remain inaccessible, and an estimated 68 percent of the road network has been destroyed.
How lack of water and sanitation infrastructure impacts health
The decimation of sanitation infrastructure has helped create the perfect conditions for the spread of diseases, especially in camps where displaced people are living in unhygienic and appalling conditions.
The lack of access to clean water, showers, and sanitation is made worse by drastic inflation of basic products like soap. Skin infections and gastrointestinal disorders are amongst the main diseases treated by MSF teams in our supported health care centers.
This sanitation catastrophe is evident in the resurgence of polio, a disease that had been absent from the Gaza Strip for 25 years, and is a direct result of people being forced to live in unsanitary conditions and the destruction of water and sanitation infrastructure by Israeli forces during the war.
How MSF is supporting water and sanitation in Gaza?
In Al-Mawasi, we have partnered with the Palestinian Agricultural Development Association (PARC) to provide displaced people with emergency latrines, solar water pump systems, a water treatment plant, tents, and other support.
We also provide more than 600,000 liters of water per day through desalination at 40 water distribution points in Al-Mawasi, Deir al-Balah, Rafah, and Khan Younis. A desalination unit in Al-Mawasi provided 7,925 gallons of drinking water per day as of late August.
Without access to proper water and sanitation infrastructure including latrines and showers, medical teams cannot keep up with the rise of conditions related to water and sanitation. As colder temperatures approach, the risk of flooding increases, and displaced people in Gaza will need winterization tents and other protective measures to face the cold season.
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