A region of protracted conflict: the perennial template of suffering
The humanitarian situation in Gaza is a catastrophe. Sixteen years of blockade has left Gaza in a fragile humanitarian state. However, the current conflict is one of many humanitarian disasters that has afflicted the region since the Arab Awakening in 2011; protracted conflicts in Syria, Yemen, Iraq, Libya and Sudan have destroyed health systems and eroded the capabilities of citizens and governments. Human development and health indicators have mostly stalled.
Sadly, when reporting on the health situation in conflict-affected countries across the Middle-East and North Africa, a common template of suffering has evolved: mass casualties and displacement, a lack of medical supplies, and egregious breaches of international humanitarian law, with the direct targeting of civilians and healthcare infrastructure. Health, mortality and injury statistics have become politicised; warring parties and international donors do not trust routine information systems even though multilateral organisations such as WHO have been using them for years. In Syria 2014, the international community even stopped counting those killed and injured as no verification method was deemed trustworthy. Truth and now statistics really are the first casualties of war, it seems.
The political economy of health: the foundation of fragile states
The historical commonality behind all these conflicts is how health and welfare systems were already paralysed by political economy factors. These have rendered them poorly equipped to handle the health complexities generated by armed conflicts, pandemics and natural disasters. Endemic corruption, a lack of accountability of domestic politicians, sectarianism, reduced international donor aid and geopolitical flux have all created a pathological civic environment and crippled public services. This cluster of issues has led to the region becoming the most unequal in the world. Where services do exist, people face large out-of-pocket payments required in dysfunctional and privatized welfare systems such as Lebanon. Public sectors, especially health, have been hollowed out by sectarianism for personal political gain. In such violent and insecure contexts, people die of avoidable disease and injuries while professional groups, such as healthcare workers, head to Europe, the Gulf and the United States, leaving domestic health systems understaffed.
Unfortunately the absence of effective governance and social cohesion in many parts of the region has created fertile conditions for authoritarian regimes and extremist factions to take control, which apparently promises some semblance of stability amidst the flux. The authoritarian bargain, is a mirage. As people struggle to cope with the chaos and insecurity of post conflict environments, they seek refuge in the most basic and essential state capability: healthcare. Investing in health and welfare systems across the region by international donors could foster a sense of stability, solidarity and trust among populations.
Gaza: where health meets munitions
The health and welfare system in Gaza was already chronically underfunded and under capacity after sixteen years of Israeli administered blockade and dependency on dwindling international donor funds. As a result, it underwent a process of de-development. Gaza, along with countries such as Lebanon, Syria and Yemen, has been stuck in a perpetual crisis where health and access to services are embroiled in the wider political situation. In oncology treatment and care in Gaza, this was particularly visible. Those with financial means or key contacts could seek specialist cancer care in neighbouring Jordan at the King Hussein Cancer Centre. However, due to lengthy delays in gaining travel permits from Israeli authorities, most patients present with advanced and end stage cancer.
The current siege and bombardment of Gaza have pushed all medical care provision over the edge leaving thousands without access to any form of even basic medical care or support. Rehabilitation and trauma centre facilities are in extremely short supply. Even if a ceasefire is agreed upon, the public health system cannot deal with any disease outbreaks, especially since water supplies have been cut and destroyed. As experience from previous armed conflicts shows, this will lead to more deaths contributing significantly to mortality suffered in war.
The mortality rates in Gaza due to bombardments are the highest of any previous conflict with Israel. In addition, blast and crush injuries pose severe challenges now and for the future. For every death, some seven to eight seriously injured adults and children will need immediate critical care and future services, should they survive. Thousands more will face mental health issues including post-traumatic stress disorder, further hindering any post conflict reconstruction efforts, and weakening the capacity of the labour force.
Understanding the political economy of health: the foundation for state capability and stability
Serious breaches of international humanitarian law (IHL) by all sides must be prosecuted, including the targeting, disruption and denial of healthcare. Failure to do so threatens to diminish the already poor reputation and influence of the UK, US and EU in the Middle East. The UK and US do not seem to have a coherent Middle East policy or an understanding of the on-the-ground and everyday challenges facing civil society in the region. The UN security council as an effective mechanism for maintaining global order and peace is already on the diplomatic ropes.
Academics and researchers in global health and medicine also need to pay far more attention to the political economy factors that lurk in the background and shape how health systems respond to crises. Too often in reports of conflicts in the region and the impacts on health, little attention or thought is given to these issues. Much of the analysis is ahistorical and apolitical. Incorporating and understanding the on-the-ground political drivers is key in the design of any early recovery and post conflict policies.
A new diplomatic and development approach to the region and holding of ‘bad actors’ to account is urgently needed if there is to be stability in the coming months and years. Sustained and large-scale investment in the basic services such as health which people rely on daily in post conflict situations would be a start. However, a nightmarish precedent has been set by the wars in Syria, Yemen and Gaza, in which the targeting of civilians, children and healthcare infrastructure (on the basis that non-state actors shelter in the bowels of hospitals) has become the norm and a tolerated part of ‘doing war’. Russia and Iran look on while they suppress their own populations and neighbours, knowing that nothing will happen in terms of being held to account. Sadly, the international community, multilaterals and the Arab region have embraced ‘bad actors’ such as Syria back into the diplomatic process, despite 12 years of the Syrian government perpetrating mass killings, torture and blowing up children and healthcare infrastructure.
For now the Quintet, including UK, European Union, Iran, Qatar and Saudi Arabia must immediately action a ceasefire in Gaza, substantial aid through the Rafah crossing and a long-term peace plan. But as of writing this, it seems a distant dream and, many would say, fantasy. The war in Gaza must end; common sense and humanitarianism must prevail.
This article is dedicated to our colleague Dr. Maisara Alrayyes, a Chevening scholar with a master’s degree from King’s College London. He was killed by an Israeli airstrike on 5 November 2023 along with his parents, two sisters, and three nephews and nieces, They remain trapped beneath the rubble due to a lack of rescue equipment. On the 8th of November both his brothers were killed while trying to find the bodies of their loved ones.
Rest in Power!
About the authors: Dr Adam P. Coutts, Department of Psychiatry and Research Associate, Centre for Business Research, University of Cambridge. Dr Coutts is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration, East of England (NIHR ARC EoE). The views expressed are those of the author and not those of the NIHR.
Professor Richard Sullivan, co-director of the Centre for Conflict and Health, King’s College, London.
Dr Saleyha Ahsan, emergency medicine doctor, PhD Candidate Health System Design Group, Department of Engineering, Newnham College, University of Cambridge.
Dr. Hanan Abukmail, MD, MPhil, Department of Public Health and Primary Care, University of Cambridge.
Professor Simon Deakin, Director of the Centre for Business Research, University of Cambridge.
Dr Vlad Chaddad, Regional Health Advisor Middle East and North Africa, International Rescue Committee, Beirut, Lebanon.
Dr Alexandra Chen, Trauma Psychologist & United Nations Advisor.
Dr Khamis Elessi is a Middle East health fellow in the Global Challenges Research Fund, Research for Health in Conflict project. Associate Professor and Head of Evidence-Based Medicine Unit at Faculty of Medicine, Islamic University, Gaza, Palestine.
Competing interests: None
Handling Editors: Seye Abimbola and Neha Faruqui