I have been following  the news from Gaza from a distance, and two observations have attracted my attention. The first is the nature of the gunshot injuries inflicted by the professional snipers, who most probably attended lessons in human anatomy; pictures have shown victims with extensive bullet exit wounds. Other pictures have shown that the bullets that were used had the ability to explode inside the body, severely damaging the soft tissues and pulverizing the bones into dust. This may indicate that the military industry was testing new weaponry in hunting fields.

The second is the condition of the public hospitals of the MoH, where the vast majority (88.7%)  of those who were wounded and treated in hospitals were managed. The number of injured exceeded those of the Israeli war on Gaza in the summer of 2014, and the wounded were treated on the floors of emergency rooms and corridors of surgical sections and operating theatres. Reports and pictures showed that two or even three patients were operated on, in one theatre, at the same time. In fact, the hospitals’ absorptive capacity was much lower than the huge number of people that were injured during the shootings; this is consistent with what happened in Winter 2008-2009 and Summer 2014, when Israel attacked Gaza.

Each time the Gaza Strip is subjected either to a military attack or to exacerbation of its harsh humanitarian realities, media outlets and reporters inform us about the collapsing health system or in the best case scenario, that the health system is on the verge of collapse. It is true that the health system in Gaza has been severely challenged by the effects of the Israeli blockade which has made the strip a hermetic enclave, but it is also true that the first casualty when war comes is the truth. Contrary to the image conveyed by media outlets and many healthcare actors, who are lobbying for funds, the healthcare system in Gaza is far from collapsing. However, it is in a state of constant turmoil and unceasing effervescent, and subject to external pressures and internal dynamics that influence both its disruption and its survival.

I understand that the last sentence challenges the convenient thinking adopted by solidarity activists who advocate for Palestinian rights and by academic scholars and health systems researchers who look at the Jungle without feeling the touch of the trees.

Health services in the Gaza strip: a long history

The  history of conflict and dispossession has made publicly provided healthcare the backbone of health services in the Gaza Strip. The exodus of more than one quarter of dispossessed Palestinians from their villages and townships, which became part of Israel, in the aftermath of the 1948 war into the Gaza Strip, which constituted only 1.4% of  Palestine, has created a humanitarian crisis. This forced the UN to intervene, offering free of charge primary healthcare through UNRWA to refugees, who constitute two thirds of Gaza Strip’s population. Under Egyptian administration, for two decades, governmental  healthcare was expanded and offered on a free of charge basis, and private provision of healthcare was limited to one Christian missionary hospital that existed in Gaza during the British mandate and to dual practicing private practitioners, who moonlighted after the end of their working hours in the public healthcare facilities.

Confronted by the free of charge healthcare, the Israelis introduced co-payments on drugs dispensed and diagnostic tests performed at governmental healthcare facilities that they controlled in Gaza, instituted  a Government Health Insurance scheme to collect revenues  and  kept hospital services stagnant, ensuring dependence on the Israeli healthcare system for the 27 year period of their control. Notwithstanding, the Israelis expanded the network of primary healthcare services and strengthened the disease control programs, since germs and viruses do not stop at the checkpoints. Inspired by both nationalist and ideological agendas, in the 1970s and 1980s, popular health committees were set up by leftwing activists.  These have, in time, become, particularly during the Intifada of stones, the backbone of Palestinian health NGOs, which were kept minuscule or at best filled niches uncovered by the publicly provided services.    

The post-Oslo period brought new developments. The first Palestinian health authority, thanks to the generous support from international donors, was able to rehabilitate hospital services  and expand the network of  primary healthcare. The global tendency to promote private provision of social and health service found a place in Palestine, but while the MoH  gave the green line for healthcare entrepreneurs  to operate in the West Bank, the poverty stricken Gaza Strip made such business a  mission impossible. To counter this, the MoH encouraged private not for profit NGOs to expand. The increasing financial adversity of the population, coupled with violence, which resulted from the failure of the Oslo process, has prevented the implementation of Bretton Woods institutions’  prescriptions.

The Second Intifada (in 2000) generated a situation in which Israelis divided  the tiny Gaza Strip into four separate enclaves and severely restricted the passage of people and goods from and to the strip, rendering those who used to work inside Israel jobless and harming the local market. Responses to this situation included the expansion of MoH hospital services to make them geographically accessible for people who were living in the shuttered areas, and the extension of enrolment in the Government  Health Insurance  scheme to make MoH  services financially affordable  for the impoverished population, resulting in a situation of semi-universal health coverage. The health services provided by NGOs expanded further during the second Intifada, and the so called “Hamas Civil Society” activity in the health sector became stronger and more visible.

The last decade, when Hamas became internally in charge of the Gaza prison facility, has produced new dynamics that have affected the healthcare system. Israel restricted passage of the supplies of  materials necessary for the operation of healthcare facilities,  isolated health cadres from around the world, and restricted the passage of patients trying to receive treatment unavailable in Gaza. International donors adopted no contact policies with Hamas and ceased, or at best decreased, their  direct support to the services of MOH controlled by Hamas Gaza Health authorities. Additionally, the Ramallah based Palestinian Authority has repeatedly interrupted its supply of material resources to the MoH facilities in Gaza. All of these, in addition to Hamas practices, have disrupted and destabilized MoH services, which are considered alongside the free of charge UNRWA primary healthcare, the major public options for healthcare .

MoH hospitals have not been dormant and have maintained their role as the main providers of secondary healthcare services, however, the average number of MoH hospital beds, admissions to them, and surgeries performed there has been declining. MoH Primary healthcare centres are fewer, because four of them were destroyed during the Israeli onslaught of 2014, although the decline in the number of primary healthcare centres and utilized services can not only be attributed to this.

On the other hand, private healthcare is thriving. Local and outside training institutions have oversupplied the healthcare market with health human resources that are not absorbed by the local health system. Disabled by the lack of financial resources, the Gaza Health Authorities have encouraged the private provision of healthcare and consciously or unconsciously started to implement advice that was given by the World Bank in the past, which was not implemented during the immediate post-Oslo period. It has increased co-payments, strengthened its revenue generating abilities, introduced  private healthcare at MoH hospitals and increasingly contracted NGO hospitals to provide healthcare for patients who co-pay for these services. While western donors and international NGOs have stayed present in this conflict affected area with symbolic connotations, Islamic donors have also become increasingly more visible.

NGO hospitals, which are staffed mainly by dual practicing physicians and which  provide services on a fee for services basis, have been thriving thanks to external funding which has shifted away from supporting the MoH services towards them. Additionally, Gaza health authorities, which reportedly treated Islamic NGOs preferentially, have encouraged their growth. The number and bed capacities of NGO hospitals and surgeries performed in them have more than doubled in the last decade. Similarly, NGO curative out-patients and primary healthcare services have grown remarkably.

An emerging two-tier health care delivery system

The challenges faced by MoH facilities, and the growth of the private health sector in the last decade have created new developments. A two-tier healthcare delivery system is emerging, whereby MoH hospitals alongside with its and UNRWA  primary healthcare, serve those who cannot afford to pay for private healthcare and those people whose  health conditions are not manageable within the private sector. Meanwhile, those who can afford payments or  who seek practitioners courtesy, swift clinical pathway  and additional attention use the services of private health sector.

As with previous post-conflict periods, it is expected that donors and the international aid industry will increase their presence in the Gaza Strip and funnel additional technical and financial support to the health sector. Will they ever learn that supporting healthcare by bypassing the Ministry of Health in Gaza under the pretext of it being under the Gaza Health Authorities controlled by Hamas, will only contribute to weakening the backbone of the entire health care system and harming the already harmed population, the majority of whom are unemployed and below the poverty line??

You probably know the answer.

Erected tents outside the MoH beggist Hospital in Gaza in order to deal with the huge influx of casulaties (credit to MoH in Gaza FB account)

Resilience in my research

In 2013, I analysed data from the latest round of the Palestinian Households Expenditure and Consumption Survey   (PHECS). I was intrigued by the paradox of resilience that emerged from the data. The p-values indicated  less incidence of catastrophic health expenditure among the population in the Gaza Strip, as compared to the more affluent Palestinians in the West Bank and that catastrophic health expenditure in the Gaza Strip was more prevalent among the better-off socioeconomic groups, than the worse-off, while it is more concentrated among the poor in the West Bank.

The data led to an epiphany – call it my very own “Newtonian” moment!

Rather smug about my small, but neat discovery, I interpreted the initial findings as being indicative of a population’s ability to withstand repeated shocks such as the Gaza Strip has been exposed to during its modern history. I have even chosen resilience as the overarching theme for my doctoral studies – to explore it from the perspective of Out Of Pocket  (OOP) expenditure on health.

As a PhD student, I have considered “resilience” as reason enough to use in my research. I have begun thinking about the appropriateness of integrating and operationalizing resilience-thinking in my research on the changes in the catastrophic OOP health expenditure in the Gaza Strip over the last three decades – a time which saw repeated economic shocks, military onslaughts and challenges to the healthcare system. The announcement by Health Systems Global that “Resilient and Responsive Health Systems for a Changing World” would be the theme of the 4^th Global Symposium on Health Systems Research in Vancouver fuelled my enthusiasm further.

The implications of the resilience lens

Resilience has been used across disciplines, especially during the last decade; yet its use in health system research is at an embryonic stage. The recent Ebola outbreak in West Africa was instrumental in framing resilience within the context of health systems. However, the fuzziness and buzz-wordiness of resilience coupled with its limited use in HSR have made its operationalization an elusive mission.

The trial of integrating resilience thinking into my doctoral research soon turned into an investigation into the appropriateness of using the resilience-lens in assessing changes in catastrophic and impoverishing OOP payments on health, the applicability of resilience to the vulnerability of the people in the besieged strip, and even questioning the usefulness  and the harmlessness of the resilience doctrine itself.

Agency and Adaptive preference

When it comes to catastrophic OOP payments, resilience could veil important issues: Agency and Adaptive preference.

The agency of individuals and households relates to the action taken by them to overcome their conditions. In contexts where access to health care is far from universal, the ability to pay may (and does) influence the ability to access health care services, which often requires the ability to pay. Context can impact health seeking behaviour; for example, poorer people may self-medicate more than the better-off. Often in low-resource settings, where available, and acceptable, public health services may be the preferred option for poorer people. The poor also rely on social capital – borrowing, selling assets, extra work, eating less, etc. – often leading quantitative data on catastrophic OOP as indicative of “resilient” populations.

Adaptive preference is the deliberate or reflexive process by which people adjust their expectations and aspirations when trying to cope with deteriorating changes in their living conditions. Preventing high OOP may happen alongside the occurrence of adaptive preference. As a result of deteriorating living conditions, and loss of  income, households or individuals may change their health seeking behaviours by choosing less expensive health providers.. Less expensive health services may decrease OOP and increase the “resilience” and ability to cope with the change in their capacity to pay, but it could also potentially be at the expense of the quality and continuity of care.

Vulnerability and resilience

Vulnerability and resilience are often thought of as two sides of a coin. One could imagine a health system (or a community or an individual) isn’t resilient because it is vulnerable; conversely it is vulnerable because it lacks resilience. In the Gaza Strip resilience and vulnerability are actually interrelated. The relationship between them is not as circular as you might imagine. Gaza is vulnerable and dangerously exposed to recurrent military onslaughts, protracted isolation and political conflict, chronic poverty, among other health system challenges.

The vulnerability of the strip and its growing population has made the political and humanitarian wings of the international community aware of the situation in which the strip is immersed. The international community has intervened since the start of the conflict and the plight in Gaza in 1948. While these have enabled people to survive, prevented starvation and disease,  they have not put an end to the conflict nor vulnerability – instead, they managed them. These interventions created a “health” system for vulnerable and surplus population. They enable people to survive and to live – but live a bare existence. Currently, more than two-thirds of the two million people in Gaza live under the poverty line, two of five are unemployed, and 80%of households receive food assistance. Despite this economic and financial deprivation, there is no starvation. Isn’t it wonderful how “resilient” the people areJ ! The health system is far from dysfunctional, but the suffering of the people continues; people queue for hours to access basic healthcare – creating, in a nutshell “resilient” systems for vulnerable populations which lack dignity.

Resilience is, in some ways at least, the vulnerability and disposability.  Resilience is created for us. For the vulnerable and disposable people. It is created for the majority of people, who should be satisfied by their mere survival and ostensible “resilience”. It is created for the people who are dangerously exposed; for us who “should” survive the repeated shocks and catastrophes, and keep smiling. It is created for us in Gaza, who could be swallowed by the sea, isolation, military attacks, and poverty, but should never give up. It is created for the global south. It is for the vulnerable; the 90% who could lose their jobs in the blink of an eye. All for the greater good of the elite; one wonders who came up with the idea of resilience.

We have gone through it – hopefully;  it was when the god sent his army of  angels, either to watch the world cup  or to bless the crashed airplanes in the desert and in the green fields.

We have gone through it; the ghosts of Azrael were haunting our strip to send men and women without ranks or uniforms on an eternal  rendez-vous  with God and  to send children,  without medals or names,   to fly their kites  in the seventh heaven.

We have gone through it; the god has blessed our place with no  earthquakes for many decades, but he sends in the men in uniform every two years or so. Clicking frantically on their mouses, they simulate his doings according to Richter’s scale.

We have gone through it; at dawn we saw a military ship coming from the eastern Mediterranean; we heard the  metal voice of the cocks  coming from the sky in the morning; sandflies, codenamed drones, were disturbing us unremittingly while they were hunting for the moon; and we witnessed the midday sun at midnight coming from everywhere.

We have gone through it; our southern gate was closed so we were  not “lost” in the desert, and military ships were in the Mediterranean so we didn’t have to drown in the sea; but the UN schools were open for us to live and die there, thank you very much; the Secretary General was seeking for the lost body of the Defense Minister’s relative, so he did not find the time to guard his schools.

We have gone through it; the International Red Cross was busy checking  the dictionary  to find the exact  meaning of words used at  the fourth Geneva convention, and  recruiting additional international expatriates; and when we called them, the telephone was ringing without a response.

We have gone through it; we managed to have some water. Who told you water is tasteless, colorless, or without smell ? Who told you about its chemical structure: H2O? it is so much more than that! Anyway, soon enough we managed to calculate our water usage: 500 drops for hair, 2000 drops for the trunk ( body), 100 drops for the mouth, 100 drops for shaving, 20 drops for each auricle, 50 for each axilla , …. We rationed almost each and every drop of water! We managed to treat our scabies, but we still have our skins itching!

We have gone through it;  electricity gently visits us for 2 hours weekly, so we have plenty of opportunity to watch the TV’s balanced and fair coverage, where broadcasters have spoken about us using the same tone they reserve for weather forecasts; we have observed the changes in the world’s geography where somehow Caracas has gotten closer to us than Makah and Lima closer than Dubai; and we are now well informed that the world was on summer vacation. When some people were concerned about us, Goebbels was dug up from his coffin  to join the services as a reservist.

We have gone through it; our hospitals were intentionally and repeatedly targeted; we were ‘informed’ that a  policeman was visiting his terminally injured child in intensive care! When we complained about our destroyed ambulances and hospitals, they told us surprisingly that they preserved the medical ethics of Rambam but did not recall that he was employed by Saladin!

We have gone through it;  when some colleagues in white coats  stood for us at a respected Journal, they have turned it upside down; they seem to have forgotten Virchow and declared that medicine is for medicine’s sake!

We have gone through it; when we told them that our refugee camp is well sealed, they responded that unfortunately a modern prison is not possible but we can make a concentration camp for you, if you insist.

We have gone through it; we managed to have Wi-Fi to log in to Facebook, and to tweet sometimes and respond to your kind emails that we are fine and still alive!

Yet, we are living dead in Gaza.

Majdi Ashour (MD) is an ex-participant of short courses of Health Policy and QMM at  ITM; he was also a New Voice in Global Health at the World Health Summit in Berlin in 2013.