At the end of January, Gaza’s public health care system had run out of 206 essential medicines – that is 40 percent of medications included in the basic Palestinian health basket. A further 27 drugs – or 6 percent of the 516 medications in the basket – were about to be depleted within days or weeks. There is a dire shortage in essential drugs such as those required for performing cardiac angiographies, treating cancer and autoimmune diseases and performing dialysis. Of a list of 853 disposable medical equipment items, 220 were expected to be unobtainable by the end of January.
“The shortage of medicines included in the basic basket is a phenomenon that has been going on for years in Gaza,” says Dr Mahmoud Daher, head of the Gaza sub office World Health Organization, in conversation with Haaretz. “But whereas in the past, 25 percent of these items were missing, since early 2017 the proportion has been growing. We are already at 46 percent,” he says, adding that $18 million is required in order to immediately restock supplies. A recent shipment from Ramallah did not significantly address the gap. The Ramallah-based Palestinian Authority government is responsible for the purchase of medicaments, but fails to send them regularly to Gaza.
The director of government hospitals in the Gaza Strip, Dr. Abdul Latif al-Haj, told Haaretz that two premature babies died last month since there weren’t enough injections to treat their respiratory distress. Injections sent recently from Ramallah will last only another three weeks, he said. Also, he noted, due to the absence of some of the medicines needed mainly for treating cancer, these patients are transferred to hospitals in East Jerusalem or in Israel. This is also true for patients requiring radiation – the one irradiator in Gaza broke down a few years ago and no money has been found to buy a new one. Absurdly, these transfers make treatment more expensive.
A recent report by Physicians for Human Rights-Israel, which examines the situation of the Gaza public health system, mentions that the shortage of lab supplies leads to a situation in which blood chemistry, hematology and cultures can be performed only for hospitalized patients, and not at out-patient clinics. This has also led to a dire shortage in blood donations.
The unavailability of drugs has been overshadowed in the last year by the worsening electricity shortage, with a daily supply of only four to eight hours. Consequently, health facilities rely on generators and a supply of emergency fuel which, according to a UN warning last Monday, will be exhausted within the next week. A January report by the World Health Organization warns that 1,715 patients will be in immediate life-threatening situations if hospitals run out of fuel.
The Israeli policy of prohibiting and restricting movement, the increasing poverty in Gaza and the economic woes of the Palestinian Authority, as well as Hamas-Fatah disputes, are the backdrop for the deterioration in the public health system and what observers warn is its imminent collapse. Add to all this Israel’s delays in granting exit permits for the sick and entry permits for spare parts for medical and diagnostic equipment – and it’s not hard to understand why the fear and anxiety of families with sick relatives has intensified.
Take, for example, the case of 50-year-old Gazan W.A., who requires dialysis. Due to power outages and dwindling generator fuel supplies his appointments were postponed several times. He also did not receive some medicines he needs and could not afford to buy them in private pharmacies.
Z., who has rheumatism, manages to pay the 240 shekels ($69) a month it costs for the medicine she was prescribed, after the government pharmacy ran out of it. On the other hand, she missed a doctor’s appointment in Ramallah because the Israeli exit permit she needed arrived several months later.
A mother of a child with a respiratory disease related that her family’s monthly income of 1,300 shekels ($373) does not allow them to buy a drug that is missing in the government pharmacy.
“I pray I’m never subjected to such helplessness where there is no medicine for a loved one or where Israel delays a permit for leaving Gaza and going for treatment,” a lecturer at the Islamic University told Haaretz.
Due to malfunctions, some vital diagnostic equipment (for MRI and CT imaging) has been out of service for a long time at the Shifa Hospital, the largest in Gaza. Another CT machine in the Al-Nasser pediatric hospital in the southern Gaza Strip is also out of service. PHR’s report mentions that “The decommissioning of scanners due to both lack of budgets for their ongoing maintenance and the difficulty of obtaining Israeli permission to deliver spare parts made these two important medical centers lose their professional reliability, and turned them into transit stations for referral to other hospitals in the Gaza Strip and elsewhere.” Al-Haj told Haaretz that there is some imaging equipment in private clinics but most people cannot afford the tests.
Hospital directors and medical teams now face extreme dilemmas of prioritization. One solution is to dilute by one third to one half the drugs given to patients, researchers from Physicians for Human Rights were told. Another solution is to close some wards, such as the oncology ward in the southern Gaza Strip, due to a shortage of 19 different cancer drugs. Other solutions are to close down smaller hospitals to save on generator fuel or to postpone elective surgery. According to the WHO, the waiting period for elective surgery is 52 weeks, instead of the recommended threshold of 24 weeks.
Since half of the required amounts of local and general anesthetics are missing, and with the shortage in disinfecting agents and antibiotics, doctors save what they have for urgent and life-saving treatment and surgery, like the incident last week in which seven people were killed and dozens injured after someone intentionally ignited a gas cylinder, following a family dispute. Another person immolated himself out of desperation over the situation, and relatives could only pray that the hospital had enough drugs to treat him and control his pain.
Hospitals also conserve their limited supplies for treating Gazans injured by Israeli army gunfire during demonstrations along the border fence. According to the WHO, 858 people required treatment over the last two months, including 180 minors.
Another burden on the system is the number of requests – 70,000 – for exemptions from health insurance payments. These cost 980 shekels a year for a family of four. Al-Haj told PHR researchers that these people used to pay for private medical tests and treatment. Now that poverty has increased they turn to the public health system but cannot afford payments. The sweeping travel restrictions imposed by Israel since 2007 and the stringent limitation on importing raw materials and on exporting produce from Gaza have caused a 40 percent unemployment rate among job seekers; the rate is 60 percent among younger people. Cuts in salaries and benefits paid by the PA to its employees have eroded their savings.
Anyone expecting the new reconciliation agreement between Hamas and Fatah, which was signed last October, to solve the financial disputes between the two Palestinian governments has been proven wrong.
Although Ramallah, seat of the PA, has in principle taken responsibility for civilian matters in Gaza, Hamas continues to collect unauthorized consumer taxes and other tariffs. The money is used for partial payment of salaries for public employees, such as thousands of doctors who were appointed by Hamas after it assumed power. Haaretz was told, however, that Hamas has stopped transferring money to government hospitals.
As long as a way is not found for including public employees appointed by Hamas in the PA payroll, Hamas will apparently continue to collect taxes. Back in 2007, PA President Mahmoud Abbas exempted Gazans from paying value-added taxes. He now wants to restore this gradually, starting at 1 percent and rising eventually to 16 percent. Gaza Strip residents, led by private sector businessman, have started voicing objections to the reinstatement of this tax. PA officials say that without the revenues, it is difficult to pay for all the social services.
The West Bank is also facing shortages in medicines but to a much lesser extent than Gaza. Hospitals in the West Bank benefit from government budgets that enable them to buy some of the drugs independently. Residents are not as poor and many more can afford to pay out of pocket. Some argue that the shortages are politically motivated, constituting part of the pressure the PA applies on Hamas. The question of why Hamas spends money on rearmament and on electricity for mosques and not on public health is being asked, but not openly.
One way hospitals draw attention to the deteriorating situation is through strikes. The Physicians for Human Rights report notes that in mid-December the company supplying food for hospitals went on strike for nine days, due to money it was owed. At the end of December cleaning staff went on strike in 13 hospitals, 54 clinics and 22 other offices, after not receiving their salaries for four months. After the dirt accumulated, medical teams at Shifa stopped working as well. The treasury in Ramallah rushed to transfer 1,800,000 shekels ($516,000) to the food and cleaning companies, which amounted to one fifth of what they are owed. On January 9 medical teams went on a warning strike, but immediately returned to their patients despite the lack of medications and their decimated salaries.