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Series on Women and Children’s Health in Conflict: Introduction

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MedGlobal Volunteer Performs Surgery at Al-Shifa Hospital in the Gaza Strip. Photo credit: MedGlobal, licensed under Creative Commons.

While conflict’s direct effects – deaths and injuries – often take the limelight, its indirect effects, including population displacement, infrastructure destruction and human insecurity commonly cause prolonged suffering that is greatly exacerbated by the length of conflict and persists long after direct hostilities cease. Though men tend to be affected more by the direct effects of a conflict, women and children, often held to be ‘vulnerable’ in context of conflict, are at much greater risk of suffering its indirect effects.[1]

This series seeks to promote the accounts of healthcare professionals who have first-hand experience dealing with medical and health issues related to women and children in protracted conflicts in the Eastern Mediterranean region. In doing so, it addresses a gap often found in scholarship of health in conflict seen from a top-down perspective, and instead foregrounds the micro-level picture. The four pieces included in the series, therefore, highlight issues which are neither routinely discussed nor prioritized.

The first article discusses maternal, sexual, and reproductive health in the Gaza Strip, and the differential levels of healthcare accessible dependent upon whether an attack is ongoing or has recently ended. In the second piece, the author shares her experience working in refugee camps in Jordan, where gender-based violence and discrimination against women are prevalent. The third article sheds light on child development in Gaza and how it is exacerbated by continual psychological trauma inflicted because of the protracted conflict and blockade. The final piece describes difficulties children with craniofacial anomalies and their families experience in accessing the care their children need in the midst of conflict and political disputes.

Publication Schedule

Part I: Maternal and Reproductive Health in the Gaza Strip: the impact of years of blockade and conflict by Maisara Alrayyes

Part II: The Voice of Gender: Shedding Light on the Impact of Emergencies and Armed Conflicts on the Health and Safety of Women and Girls by Asmaa Essa

Part III: The hidden face of the blockade and wars: Palestinian children with psychological wounds by Bahzad Alakhras

Part IV: Children with craniofacial anomalies in the Gaza Strip: treatment options and access to care by Wafaa Alzaanin

[1] Craig, Sophia. “Effects of Conflict on Societies.” In Conflict and Health, 14–24. Berkshire: McGraw-Hill Education, 2012.

Conflict & Health in the Eastern Mediterranean Series: Life after traumatic amputations in the Gaza Strip and the use of drones against civilians

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by Dr Hanne Heszlein-Lossius, MD, PhD & Dr Anas M. Ismail, MD

A child with war-related amputation sits on his wheelchair in his home in Gaza City. Photo by Dr Hanne Heszlein-Lossius.

This article is part of our Conflict & Health in the Eastern Mediterranean Series. Read the Series Introduction.

Almost 15 years of blockade and recurrent military incursions have caused significant deteriorations in living conditions for the civilian population in Gaza. Over this period, and often as a direct result of Israeli military actions, many civilians have suffered the loss of one or more of their limbs, with the latest military actions against the Great March of Return resulting in 156 new amputees. Research on the consequences, both medical and in terms of quality of life, of losing arm(s) or leg(s) among the civilian population, in such military attacks, is quite scarce.

Both authors were involved, with Professor Mads Gilbert from University of Tromsø and Palestinian doctors and research colleagues in Gaza, in a research project, culminating with a PhD project by Dr Heszlein-Lossius, that studied civilian amputees from aerial bombardments, especially drones, in Gaza. Starting in the summer of 2014, the project collected data on these patients to find out more about the long-term consequences and to understand how their amputation trauma affected their lives. The project included 254 patients with war-related traumatic extremity amputations resulting from the different Israeli military operations: Summer Rain, Cast Lead, Pillar of Defense, and Protective Edge.

The studies we produced revealed that the majority of the amputated Palestinians were young, well-educated men with large financial responsibilities, and who were often the family’s sole breadwinner. Most of the amputations were major (above the level of the wrist or the ankle) and caused severe physical disability. Pain and psychological distress were among the common problems suffered by the survivors. To lose the ability to work and the ability to care for one’s family and hence put food on the table seemed to be an important trauma adding to the pain and loss of arms or legs. One could say that the poverty they were forced into often became the most painful long-term trauma.

While investigating the different types of weapons used against the civilians in our study, it became clear to us that many of the patients had worrying symptoms and needed further medical care. 105 of the 254 patients had symptoms and were referred to the main hospital in Gaza, Al-Shifa Hospital. The patients had a variety of findings such as liver abnormalities, night sweats, malaise, and weight loss. In addition, many patients had problems at their amputation stump, such as ulceration, palpable lumps or pain.

We were also interested in researching the type of military weapons that had caused the amputation(s) among our patients in the study. We found that unarmed military airplanes carrying explosive weapons (drones) were the most common cause of amputation, a feature of the military operations in Gaza that was investigated by Human Rights Watch. These drone-attacks also caused the most severe amputations and patients who experienced them needed more surgical operations than any other type of weapons injury.

Drones have been a subject of heated debate in recent years after the expansion of their use under President Obama. Promoted as a military tool utilized to minimize civilian casualties, its use in many settings has been challenged from both humanitarian law and ethical perspectives. Moreover, its actual effectiveness as a means to achieve its intended aims, delivering surgical strikes against targets while minimizing civilian losses, is also disputed. A documentary produced in 2014 that showcases Pakistani casualties from drone attacks clearly shows how civilians, including children, are often directly targeted with complete impunity.

Following our experience in Gaza, it is very clear that in order to improve the quality of life for patients with war-related traumatic amputations the underlying reasons for their suffering must be addressed. The blockade and the recurrent military attacks certainly cause deterioration in human security in Gaza, and this is especially true for those directly affected by military actions. The use of modern weapons such as drones require greater restrictions and a humanitarian legal framework to protect civilians, in both Gaza and other areas of armed conflict in our world.

Conflict & Health in the Eastern Mediterranean Series: Medical Referrals in Gaza: Uncertainty and Agony for Palestinian Patients

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by Anas M. Ismail

A mother carries her ill child through the 1-km fenced corridor towards the borders with Israel at Erez checkpoint.
Photo Credit: International Committee of the Red Cross

This article is part of our Conflict & Health in the Eastern Mediterranean Series. Read the Series Introduction.

Palestinians in the Gaza Strip live in a different reality. Since 2007, Gaza has been under a blockade imposed by Israeli authorities, which determines, via a system of security permits, what and who can come in and out. This regime also covers medical patients, many of whom need treatment that is unavailable in the Gaza Strip. For patients, including children, living in conflict settings, their survival depends more often on political considerations than it does on medicine and expertise. Such patients go through a tedious and painfully uncertain process to get necessary documents and permits needed to travel to hospitals abroad, mainly in the West Bank and Israel.

The 14-year-old blockade and the recurrent attacks on the Gaza Strip have left the healthcare system fragile and lacking equipment, health care personnel, and reliable supplies of electricity and water1. The blockade has become a social determinant of public health in the Gaza Strip2. The two million people living there face shortages in many diagnostic procedures and treatment options.  This is particularly an issue for cancer, cardiovascular, paediatric, and neurosurgical patients.

The Palestinian Ministry of Health (MoH) estimated, in its annual report for 2018, that there were nearly 110,000 referrals of Palestinian patients for services outside MoH facilities, with a total cost of nearly $200 million. Of the referrals, more than 30,000 were for patients from Gaza and amongst those, oncology patients were by far the most referred category. Shortages which lead to this trend include, but are not limited to, PET/CT scans to detect cancer metastasis, chemotherapy and radiotherapy for cancer, cardiothoracic and neurosurgical surgeries, and other diagnostic and treatment modalities. The patients who need these procedures have to navigate the intricacies of the local healthcare system whilst simultaneously traversing Israeli border controls. This journey is illustrated in a video produced by the World Health Organization (WHO) office in the occupied Palestinian territories (oPt).

When a patient in Gaza is told that the diagnostic procedure or treatment option they need is not available locally, they receive a detailed official report with their case and what they need to be referred for. The report is approved by hospital directors and sent to the local MoH which liaises with hospitals in the West Bank or Israel to book an appointment for the patients. After that, the MoH sends the reports and the appointment to the ministry in charge of liaising with the Israeli occupation, the Ministry of Civil Affairs (MoCA). The MoCA then files a request for a permit for the patient and a companion to leave on the day of the appointment to the Coordinator of Government Activities in the Territories (COGAT), which is the unit in the Israeli Ministry of Defence that deals with civilian affairs of people in the oPt. The request could then be accepted, and the patient would travel along with a companion to the hospital, or the request could be delayed or even denied, depending on COGAT and a security check by the intelligence agencies.

The WHO keeps track of monthly referral activities, and it estimated in 2018 that only about 60% of patients’ permits are approved in time, with the remaining being either denied or delayed. For cancer patients, denial or delay means missing their chemotherapy and radiotherapy cycles, which is detrimental to their survival as shown in the video by Medical Aid for Palestine. In the case of denial or delay the patients have to go through the same cycle starting with a new report, a new appointment, and a new permit request. Some patients, like in the WHO video, go through this procedure multiple times. Furthermore, the report by WHO highlighted that only 48% of permits for companions are approved, meaning that 12% of patients, including children, travel on their own to receive care. Moreover, patients whose permits were approved and cross the border can be, and are often, subject to security interrogation.

Patient referrals have been even further complicated by politics and the coronavirus pandemic in recent times. In May 2020, the Palestinian Authorities ceased almost all coordination with Israel in response to Israeli plans for annexation of illegal settlements in the West Bank. At the same time this happened, the oPt was experiencing the first wave of the coronavirus pandemic. Citing public health measures, Israeli authorities introduced further restrictions on border crossing, making things even harder for Palestinian patients needing care outside Gaza. As a result, permits issued for patients from the Gaza Strip declined drastically. The number of applications for permits from Gaza patients had dropped from over 1,700 patient applications for permits in February 2020 down to around 160 in May 2020.

In desperation, patients turned to the WHO office and human rights organizations to obtain much needed permits to seek medical care in the West Bank and Israel. However, this alternative approach shortly ended following statements by Israel implying that human rights centres could replace MoCA. Patients seemed to be trapped in a deadlock with no clear mechanism of how to access the care they need. As the situation gathered attention, human rights organizations started advocating for patients. In a letter to the Israeli Defence Minister, Attorney General, and head of COGAT, five Israeli human rights organizations called for the removal of all obstacles preventing patients from Gaza accessing the care they need.

Patients in the Gaza Strip have had to handle the complexities of occupation and living in a protracted conflict, with all that has meant in terms of arbitrary security procedures, time-consuming bureaucratic processes, and political disputes. In addition to living with malign conditions, they have had to endure the stresses of both the fractured and inadequate local health system and the uncertainty attached to accessing badly needed care abroad. Under International Humanitarian Law, those needing medical care should be spared from ongoing conflict and should be allowed to receive the care they need. The blockade of the Gaza Strip, which is a form of illegal collective punishment, has so far detrimentally affected the fate of patients needing care outside. While the Israeli-Palestinian conflict may be far from reaching an end, the suffering of those patients should not be.

  1. Smith, Ron J. “Healthcare under Siege: Geopolitics of Medical Service Provision in the Gaza Strip.” Social Science & Medicine 146 (2015): 332–40. https://doi.org/10.1016/j.socscimed.2015.10.018.
  2. Smith, Ron J. “The Effects of the Israeli Siege on Health Provision in the Gaza Strip: a Qualitative and Theoretical Analysis.” The Lancet 391 (2018). https://doi.org/10.1016/s0140-6736(18)30403-3.
  3. Devi, Sharmila. “Funding Crisis Threatens Palestinian Refugee Agency.” The Lancet 396, no. 10264 (2020): 1714. https://doi.org/10.1016/s0140-6736(20)32527-7.

Dr Anas Ismail is studying an MSc in global health with conflict and security at KCL. He graduated as a medical doctor from Gaza. He is interested in studying impact of conflict on health, especially health services and delivery.

Dr Ismail is the Production Manager at Strife Blog and a Series Editor. Follow him on Twitter at @anas_anesto.

Series Introduction: Conflict and Health in the Eastern Mediterranean

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by Anas Ismail

Photo by Andrey Metelev on Unsplash

Conflict is known to affect health in a myriad of ways[1] including, but not limited to, attacks on health workers and facilities, disruption of access to health services, deterioration of water and sanitation infrastructure, and interruption of training and education for medical students and junior doctors. The more severe and long-lasting the conflict, the more significant its effects on health and the harder it will be to recover and improve health in post-conflict situations. Moreover, the impacts of conflict extend beyond the national borders in which they occur, and bleed over into neighbouring states whose governance, in the face of conflicts’ destabilizing effects and mass refugee flows, is significantly challenged.

The Eastern Mediterranean is home to one of the oldest conflicts, that between Israel and Palestine, and one of the most devastating, the Syrian civil war.

In Palestine, over five decades of occupation have taken their toll on all aspects of healthcare from medical education to patient care and life conditions, all aspects further explored in this series. In Syria, the conflict has been characterized by the weaponization of healthcare, i.e. attacking or withholding healthcare as a strategy of war. Moreover, while the parties to these conflicts suffer extensively, other countries in the region are also struggling from their spill-over effects alongside their own internal divisions and unrest. Lebanon continues to endure an unprecedented economic crisis, deep internal divisions, and lack of proper governance on the political level – all whilst hosting nearly 1.5 million Syrian refugees. These have had a significant  impact on the country’s youth whose mental health needs seems to be far from being met in a country where psychiatric and psychological services are largely neglected, with a treatment gap close to 90%. Jordan, on the other hand, enjoys  relatively stable governance and economic conditions, but it has been strained  by surrounding instability. As a result of the protracted Israeli-Palestinian conflict, it hosts 2.2 million Palestinian refugees, the most of any country, and over the past decade these have been joined by 1 million Syrian refugees, meaning that over 30% of Jordan’s total resident population are displaced peoples.

This series aims to capture various experiences of healthcare delivery and medical education in the region. The first article brings to light how medical education is being provided completely online for the first time in Gaza under settings of protracted conflict, chronic electricity shortage, and economic impoverishment. The second piece discusses the underlying causes of the looming epidemic of mental health disorders among the youth in Lebanon and how the economic crisis is impacting it. The third article illuminates the intricacies and security implications of patients in Gaza needing, and seeking, treatment abroad. In the fourth piece, the author, a Syrian doctor in diaspora, discusses how attacking the healthcare work force in Syria is affecting the provision of health and what needs to be done. The final piece describes the far-reaching impact of war-related amputations on civilians in the Gaza Strip and argues how modern warfare, such as drone attacks, are causing an increase in such injuries.

Series Publication Schedule

  • 26 April 2021 – Part I: Medical education under blockade, protracted conflict and constant warfare. By Alaa Ismail
  • 27 April 2021 – Part II: Lebanon in Ashes: A Looming Mental Health Crisis? By Loubaba Al Wazir
  • 28 April 2021 – Part III: Medical Referrals in Gaza: Uncertainty and Agony for Palestinians Patients. By Anas Ismail
  • 29 April 2021 – Part IV: How does the Syrian Civil War affect health care workers? By Abdullah Al Houri
  • 30 April 2021 – Part V: Life after traumatic amputations in the Gaza Strip. By Hanne Heszlein-Lossius

[1] Howard, Natasha, Hossain, Mazeda, Ho, Lara. “Effects of Conflict on Heath.” In Conflict and Health, 25–32. Berkshire: McGraw-Hill Education, 2012.

Anas Ismail is a medical doctor originally from Gaza, Palestine, where he received his education and training. As a citizen of Gaza, and later as a medical student, he personally lived the impact that conflict has on life in general and on healthcare in specific. This led him to an interest in global health as a means of learning more about the relationship between conflict and health.

With a joint scholarship from the Chevening Awards and the Said Foundation, Anas is currently studying MSc Global health with conflict and security at King’s College, London. He is the Production Manager for Strife Blog and a Series Editor at Strife.