The Public Health Implications of the Humanitarian Crisis in Gaza

The humanitarian crisis in Gaza has had, and will continue to have, severe impacts on public health. At a panel discussion convened by Emory’s Rollins School of Public Health on November 20, speakers shared how the heightened conflict amid the Israel-Hamas war has deteriorated Gaza’s health care infrastructure, leading to an over-burdened health workforce, dangerously diminished medical supplies, and extremely high levels of poor health outcomes.

Invited speakers were medical doctors and researchers with years of experience working in Gaza and other conflict zones. The panelists were:

• Erik Fosse, MD, surgeon and co-founder of the Norwegian Aid Committee (NORWAC)
• Shariq Sayeed, MD, vascular surgeon working with the Islamic Medical Association of North America
• Deirdre Nunan, MD, orthopedic surgeon working with IDEALS
• Ola Ziara, MD, Palestinian pediatrician and former Emory University Humphrey Fellow
• Leslie Roberts, PhD, professor emeritus of population and family health at Columbia University Mailman School of Public Health

The State of Health Care Infrastructure in Gaza

Many of the panelists have seen firsthand how the ongoing conflict has hobbled the Gazan health care system, both in physical infrastructure and in less tangible ways.

“In the north, you’re looking at massive destruction of the health care system,” said Nunan, who spoke in a pre-recorded interview from a one-month medical service in Gaza. “Hospitals have structural damages. There have been attacks on water filtration systems, solar panels, electricity systems, generators, and oxygen supply. There are hospitals with no surgeons where there are influxes of casualties coming every day.”

In southeastern Gaza, where Nunan was stationed in European Gaza Hospital, she describes the situation as “the best-case scenario,” but there are still significant challenges. Among those are shortages of gauze and basic medications like Tylenol, high infection rates, and medical staff working under extreme stress in unfamiliar environments.

Sayeed spent time working at the same hospital in April 2024 and noted similar workforce challenges.

“The emergency department was relatively short-staffed,” he says. “It was mostly staffed by medical students and only one or two resident physicians. So, our team was coming in at night to try to help.”

Beyond basic supplies like medicine, hospitals in Gaza also lack the medical equipment they need, including things like x-ray machines and oxygen concentrators. This is despite decades of work from organizations like NORWAC to build infrastructure, systems, and physician capacity.

“We believe that if a society is going to be able to cope with situations like the one in Gaza, you need to build resilient health care during peace time,” said Fosse. “In Gaza, we have been working with the Ministry of Health since 1994 and building a national system of oxygen concentrators in both the West Bank and Gaza. We’ve been helping them build sterile centers to clean equipment, laundry services…everything that’s needed to run a hospital and to make them independent, as much as possible, from outside aid.”

After months of destruction, much of that infrastructure no longer exists. According to Fosse, there have also been challenges with bringing in new medical equipment and parts to repair what has been damaged. This has led to hospitals having to operate with far less, or worse, equipment than they need.

“In European Gaza Hospital, when I was there in February, we had only one portable x-ray machine,” said Fosse. “That’s far too little when we have all of these injuries coming in.”

Ziara, who left Gaza to start her Humphrey Fellowship year at Emory in summer 2023, shared her experience as a doctor and her heartbreak at the state of the health care system.

“When I left, we had infection prevention measures, we had good labs to identify organisms. I worked with Doctors Without Borders for years on a limb reconstruction surgery program that worked with experts from around the world to build the capacity of professionals in Gaza. We had an amazing antibiotic stewardship program. We had made huge steps forward in our health system, and seeing on the news that hospitals have been bombed, that there is no longer a children’s hospital in the north…it breaks my heart into pieces,” she said.

Despite these challenges, hospitals remain a refuge for Gazan people who are seeking a safe haven. That leads to family members sheltering in the hospital with patients, contributing to extremely overcrowded conditions.

What This Means for Health

The state of the hospital system in Gaza, even in the southern part of the country where medical facilities are still functioning at a higher level, is having major impacts on health. For example, infection prevention and control is non-existent amid current conditions.

“The overcrowding of the hospital has made it almost impossible to keep things clean from a post-operative, surgical perspective,” said Sayeed. “For the patients I operated on, I had a 100% infection rate.”

Doctors also face difficult choices when deciding on care for their patients. Some standard treatments may lead to even higher chances of infection or may hinder a patient’s ability to survive in the current conditions faced by people in Gaza.  

“I was looking at patients and having to consider if they would be reinjured or killed before they heal from this injury, or if this injury that I was trying to treat will impact their ability to survive,” says Nunan. “Never before in my career have I found myself making treatment recommendations because I have to consider that my patients need to be able to run away from an attack.”

The health impacts are also not equal across all groups. Roberts notes that “normally the weakest, most vulnerable parts of a society are what get worse” during conflicts. In Gaza, this can be seen in how the ongoing conflict is affecting women and children.

“There is no children’s hospital in the north, and there is no food for children everywhere,” said Ziara, discussing how children’s health has dramatically changed in Gaza since the fall of 2023. “I worked for fifteen years as a pediatrician in Gaza, and I never saw a malnutrition case because of not having food. Now, to know that the UNICEF and many other organizations report that one among three children [under two years old] is severely malnourished…It is unfathomable.”

People with chronic conditions are also affected by the breakdown of the health care system. When resources are taken up by traumatic injuries, and displaced people have to travel further to receive care, the delays can lead to much worse outcomes for problems that would normally be routine. This means that something like a diabetic foot ulcer takes longer to be addressed, and even once it can be treated, infection is much more likely, which can lead to a normally avoidable progression such as amputation.

Measuring Mortality

Preventable illness, chronic disease progression, and malnutrition contribute greatly to death tolls in resource-poor conflict zones like Gaza.

“During times of war, in wealthy societies, most deaths are from violence,” said Roberts. “But in the poorest settings, when war and conflict come, most deaths are from the same things people were dying of before—malaria, or respiratory infections, or whatever it may be. They just start dying at a much higher rate.”

Measuring and reporting on deaths during times of conflict in those poorest settings, however, can be complicated. Death surveillance in those countries is almost universally poor, and during war those systems tend to collapse. This leads to reliance on household surveys done by organizations like Doctors Without Borders, which are not necessarily completely accurate.

However, the mortality data coming out of Gaza has not faced these types of challenges, according to Roberts. He shared that, “in the 40 times that I’ve measured mortality in times of war, I’ve never seen anything like we are seeing in Gaza.” In March 2024, he defended the rigor of the death surveillance process in an op-ed in TIME magazine. During the panel, Roberts reiterated his points from that article, and stated that the death toll has likely been undercounted, if anything, due to the collapse of the health care system in northern Gaza.