THE COVID-19 PANDEMIC AND DEADLY CONFLICT
What’s new? COVID-19 cases have appeared in the Gaza Strip, where close to two million Palestinians live in 365 sq km, many of them in crowded refugee camps where social distancing is hardly feasible.
Why does it matter? A major outbreak of the illness would swiftly overwhelm Gaza’s health care system, which has been devastated by years of war and Israeli blockade. The death toll could be horrific.
What should be done? The Hamas government should maintain its quarantine measures and step up other efforts to contain the virus’s spread. Israel should lift the blockade for medical supplies and allow Palestinians out of the strip should they require hospitalisation.
COVID-19 has entered the Gaza Strip, one of the world’s most densely populated territories. If efforts by the Hamas government fail to contain it, the virus could rampage through the Palestinian population of nearly two million, the majority of whom live in tightly packed refugee camps. Gaza’s health infrastructure – crippled by an Israeli blockade and further damaged in war – will be unable to cope with the worst-case scenario wherein tens of thousands of people require hospitalisation when there are only 2,500 beds available. As long as containment remains possible, the Hamas government should strengthen its lockdown measures and build more quarantine facilities with the means available. Israel, for its part, should lift its blockade on Gaza to allow desperately needed medical equipment and supplies to get in. It should also prepare to help Palestinians in Gaza who contract the virus and require types of care unavailable in the impoverished strip.
As the occupying power in Gaza, Israel has a duty to care for the population under its control. In the case of COVID-19, it also has an interest, as the virus knows no borders. If only for these reasons, Israel should relax the blockade to let in hygiene kits, ventilators and other supplies, and suspend the requirement for transit permits for those who require hospitalisation outside of Gaza. It should also support international efforts to erect field hospitals in and around the Gaza Strip, facilitate the entry of medical personnel willing to volunteer their services, and develop a plan for treating Palestinians from Gaza who need urgent medical attention in Israel.
A catastrophe of massive proportions could await Palestinians in Gaza who already have suffered far too much. Hamas, Israel and others need to take urgent steps to minimise the fallout.
Hamas’s Quarantine and Containment Efforts
On the evening of 21 March, Gaza’s health ministry confirmed the area’s first two cases of COVID-19. The men, both Palestinians returning from Pakistan, were placed under quarantine in a field hospital near the Rafah border crossing into Egypt. The authorities assured the public that all those who had been in contact with the travellers were also quarantined. That night, the authorities sent fire trucks to hose down pavements and streets, and police vehicles roamed the strip, calling on people not to gather in groups. Gaza’s chief of general security and his deputy were also put in quarantine, given that they had been in contact with the two travellers while inspecting the isolation area. On 25 March, the quarantine facilities where the two were being held announced that seven more individuals had tested positive for the virus. By 30 March, the total number of cases had risen to ten.
Even before 21 March, with cases mounting in Israel, Jerusalem and the West Bank, and stories of the pandemic in Italy and Spain trickling in, the public in Gaza began to turn more vigilant. In the cities, some started wearing gloves and masks, and buying alcohol-based hand sanitisers and thermometers – imported goods that were soon out of stock. In the more densely populated refugee camps, by contrast, life went on with little indication that anyone was taking precautions against the virus. The camps bustled with people. Markets were open, barber shops were doing business as usual, mourners gathered at a memorial service and people ambled in the streets. Overall, the strip remained sheltered from the shock waves felt around the world. People joked on social media that they had been under lockdown for much longer than the two weeks required for self-isolation elsewhere. One tweet read: “Dear world, how does it feel to be quarantined? Yours sincerely, 14-years besieged Gaza”.
The Hamas government had focused on preventing the virus’s entry. Given that the strip has been under a quasi-hermetic blockade since 2007, with only a handful of tightly monitored crossings into Israel and Egypt, this task appeared more manageable than elsewhere in the world. For once, Gaza’s forced isolation appeared to have a silver lining. On 15 March, Gaza’s Ministry of Health announced that travellers entering from either Rafah or the Beit Hanoun/Erez crossing with Israel would be placed under compulsory quarantine for two weeks, subsequently raised to three. Commercial crossings, meanwhile, which are separate transfer points for the import and export of goods, remained open. The authorities began selecting hotels, schools and public venues to be converted into quarantine facilities in case of an outbreak, as well as building new isolation wards. At the time of writing, there were 24 quarantine facilities, with 1,568 individuals held in government quarantine, including the two diagnosed men and any other traveller who entered the strip after 15 March, and another 1,205 in self-enforced home quarantine.
On 21 March, after the two men were quarantined, the police issued a statement noting that authorities would put a halt to wedding gatherings, public celebrations, funeral services and memorials; close cafés and restaurants; suspend Friday noon prayers in mosques; and shut down the port until 27 March, effective the next day. Fishermen were allowed to continue practicing their trade. On 23 March, the Health Ministry suspended all elective surgeries and medical procedures. On 25 March, the Awqaf [religious endowments] and Religious Affairs Ministry closed houses of Muslim worship for two weeks and invited “mothers and fathers [to] turn [their] homes into schools and mosques”.
The worry in Gaza is not whether supermarkets might run out of supplies but where families might get the money to purchase them. Poverty is staggering: more than 80 per cent of the population relies on humanitarian aid.
After the diagnosis of the two cases, there was a sense of panic in cities around the strip. Markets were busy, and those who could afford to buy supplies stocked up on food, preparing for long stays at home. These people, however, were the exception. The worry in Gaza is not whether supermarkets might run out of supplies but where families might get the money to purchase them. Poverty is staggering: more than 80 per cent of the population relies on humanitarian aid. Pharmacists report that persons have been coming to buy Paracetamol, antibiotics and other anti-inflammatory medications by the pill rather than the packet. Most Palestinians in Gaza cannot afford even locally manufactured sterilisers, let alone the imported sanitisers, gloves and masks, which are in any case no longer available. Some families bought single masks and gloves for repeated use, thereby rendering them ineffective. One joke that has circulated is that a mother chided her child for wearing a mask too long: it was the sibling’s turn.
A Battered Health Care System
After Hamas assumed control of the strip in 2007 (following elections the previous year), the Israeli government imposed a blockade that continues to severely restrict the movement of people and goods into and out of the territory. Apart from devastating the economy – in what the UN has termed a form of collective punishment – the blockade has crippled Gaza’s health care sector. The World Health Organization has said that, while Israel generally allows pharmaceuticals and disposables to enter Gaza because of their humanitarian nature, Israel has either delayed or prevented the import of medical equipment, consumables and spare parts. The Palestinian Authority in the West Bank has exacerbated this shortage by reducing the transfer of medicines into Gaza as part of its attempt to bring Hamas to its knees and replace it as the legitimate government. Due to the blockade, many medical staff have left in search of better opportunities elsewhere. The Trump administration’s moves to defund the UN Relief and Works Agency (UNRWA), a major health service provider in the strip, have further weakened the system.
Israeli military attacks have also badly damaged Gaza’s health infrastructure over the years. Human rights organisations have repeatedly accused Israel of targeting Gaza’s hospitals, ambulances and health care personnel during conflict. Israel’s systematic targeting of civilians during the Great March of Return protests in 2018 and 2019 placed additional stress on the health sector. Siege and serial military assault have taken an enormous cumulative toll. Jamie McGoldrick, who chairs the UN’s COVID-19 task force for the occupied territories, said that this pandemic could be a “tipping point” in Gaza, referring to the possible implosion of the health system.
It is not merely the health care sector’s weakness that threatens Gaza’s ability to manage a COVID-19 outbreak. The precipitous decline in the quality of life as a result of the blockade has undermined basic hygiene, most evident in the shortage of water and sewage treatment facilities, which further hampers efforts to prevent the virus’s spread. Furthermore, the Gaza Strip is one of the most densely populated territories on the planet, with close to two million Palestinians living in 365 sq km. Containment efforts, therefore, are likely to face significant challenges, and a comprehensive lockdown, or even effective social distancing, in refugee camps or districts such as Jabaliya, Shati, Shuja’iyya or Khan Younis is almost impossible to imagine.
Alongside the shortage of beds and basic protective gear and hygiene supplies for medical staff is a stark shortfall of ICU equipment and ventilators.
For these reasons, the discovery of two infected persons on 21 March, and an additional eight cases by 30 March, inaugurated what many deem a nightmare scenario. Everyone knows that the authorities are ill-equipped to contain the spread of the virus or to care for those afflicted. Some estimates suggest that as much as a quarter or half of any population is vulnerable to contracting the disease, and that 20 per cent of these people will require hospitalisation. If correct, these estimates would translate into a need for at least 100,000 beds over the length of the outbreak in Gaza. Yet the territory has only 2,500 beds, give or take a few. Alongside the shortage of beds and basic protective gear and hygiene supplies for medical staff is a stark shortfall of ICU equipment and ventilators. Gaza’s health ministry notes that Gaza has 65 ventilators in use or in poor condition, stressing that the strip urgently needs at least 150 more. UNRWA has no hospitals and offers only outpatient care.
The lack of capacity to deal with medical emergencies is a familiar challenge in Gaza. Palestinians have had to endure years of seeking permits from Israel to allow them to travel outside the strip for treatment. Of more than 2,000 such applications submitted per month, Israel approves 1,200 on average. Stories of Palestinians losing their lives, or being unable to travel with loved ones, including children who are undergoing major surgery or treatments elsewhere, are frequent. In the face of a global pandemic, Israeli restrictions on medical supplies and travel for medical treatment could result in thousands of preventable deaths. According to an Israeli official, as many as 50,000 Palestinians in Gaza could die in a dire yet plausible scenario of mass contagion. Gaza’s UNRWA director has referred to the possibly imminent outbreak as “a disaster of gigantic proportions”.
The Need for Urgent Mitigating Measures
There is no sign as yet that Israeli Prime Minister Benjamin Netanyahu’s caretaker government might ease the blockade, use its own resources to send medical supplies to Gaza or incorporate Gaza’s medical needs in plans to increase Israel’s COVID-19 preparedness. An Israeli official explained that the government’s role is to act as “a valve” – by allowing international aid to enter in an exception to its closure policy – rather than to provide such support itself or treat patients from Gaza in Israeli hospitals. Even if Israel opened all its hospitals to Palestinians in Gaza who require hospitalisation without caring for its own citizens, it would be able to accommodate only 5,000 of the most severe cases. As a state comptroller’s report explained, Israel’s own health system is underprepared and overstretched. A former commander of the Coordinator of Government Activities in the Territories (COGAT), the Israeli army unit that deals with civilian needs in the West Bank and Gaza, said: “Israel cannot be blamed, [as] Israel is suffering already from this virus”. Accordingly, Israel has thus far limited its response to facilitating the entry into Gaza of 500 WHO-funded testing kits and 1,000 protective suits.
The Israeli government’s stance overlooks both Israel’s role in creating the medical crisis in Gaza and its responsibility, under international law, to care for the well-being of populations under its occupation.
The Israeli government’s stance overlooks both Israel’s role in creating the medical crisis in Gaza and its responsibility, under international law, to care for the well-being of populations under its occupation. As Israeli lawyer Sari Bashi noted: “Israel exercises control [over Gaza]. It must protect their right to health, to the same extent that it protects the right to health of Israeli citizens”. The non-governmental organisation Israeli Physicians for Human Rights has called on Israel’s health ministry to provide assistance to medical authorities in Gaza, with its director of the occupied territories noting: “In light of the ongoing siege, Israel is responsible by virtue of international law to provide the required means to the Health Ministry in Gaza”. The government rejects the international consensus that Gaza is occupied territory, arguing that it is no longer responsible for the strip, particularly after its unilateral disengagement in 2005. It views Gaza through the prism of its conflict with Hamas, and accordingly, believes that its obligation is limited to channelling humanitarian aid to the strip.
The Hamas government has demanded that Israel lift the blockade to allow it to deal with the pandemic. It has issued statements indicating that it holds Israel fully accountable for whatever happens in Gaza, while at the same time assuming no responsibility for its own contribution to the strip’s economic woes. On 19 March, two days before the diagnosis of the two cases, the Hamas government’s health ministry called on the international community to pressure Israel to lift the blockade, and on humanitarian organisations to supply needed medical equipment urgently.
Some organisations and donors, anticipating a calamity, have begun to step in. The UN has earmarked $1.5 million for medical interventions in the Occupied Territories. Non-governmental organisations, such as Medical Aid for Palestinians, have begun providing hygiene kits for those in quarantine. But such supplies are clearly insufficient to cope with a major uncontained outbreak. Given the challenges that donor countries are facing domestically, and the hit that international organisations have taken as a result of COVID-19’s rapid spread, the safety net is fuller of holes than ever.
The government should sustain and expand efforts to build quarantine facilities and it must be even stricter in enforcing lockdown measures.
Given this reality, efforts to contain the crisis must continue even as the Hamas government takes steps to prepare for the worst-case scenario. The government should sustain and expand efforts to build quarantine facilities and it must be even stricter in enforcing lockdown measures. To succeed at the latter task, it will need to raise awareness in refugee camps and other congested urban areas. Health officials have indicated that containment might still be possible. Indeed, it remains the most practical course of action for the authorities.
The Israeli government, meanwhile, should lift the blockade for medical purposes in the coming days and weeks. The government should immediately allow the untrammelled transfer of required medical supplies, hygiene kits and ventilators into Gaza and suspend the requirement for transit permits for those who require hospitalisation outside of Gaza. Israel should also support international efforts to erect field hospitals in and around the strip, facilitate the entry of medical personnel who could mitigate Gaza’s shortage of doctors, and develop a plan within its own medical sector for treating Palestinians from Gaza who contract the virus and require hospitalisation in Israel. Apart from being duty-bound, under international law, to secure the health of Palestinians in Gaza, Israel should see the value of such measures for mitigating the possibility of further contagion, and another outbreak, within Israel.
The arrival of COVID-19 in Gaza is a sobering moment. It reveals just how vulnerable are the two million Palestinians living there. Successive Israeli governments have presented the Gaza Strip as a separate entity under Hamas’s jurisdiction since 2007, as part of an effort to isolate the area and disengage from it. But the appearance of coronavirus and the limitations that restrict Gaza’s ability to deal with it demonstrate that the enclave remains under Israel’s ultimate control. Now perhaps more than ever, Israel should assume its responsibility as the sovereign power largely holding the well-being of Palestinians in Gaza in its hands.
Gaza City/Jerusalem/Brussels, 1 April 2020