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Conflict and Health in the Eastern Mediterranean

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: How does the Syrian Civil War affect health care workers?

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by Dr Abdullah Alhouri

Syrian Health care workers gathered in New York City calling for an end to attacks on health care facilities in Syria

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

Since 2011, Syria has been ensnared in an armed conflict [1] which has had a devastating impact on health care services. Most crucially, the foundations of Syria’s health care infrastructure have been destroyed. This has resulted in a dramatic increase in both morbidity and mortality in the country, and it is expected that this will only continue to worsen [2].

One of the most exacerbating factors behind the national health crisis is the falling numbers of trained health care workers (HCWs), who have often been victims of violence during the conflict and have been consequently forced to leave the country. These HCWs play a vital role in health care delivery during conflict and in the reconstruction of the health care system following a cessation of conflict [3].

Doctors, and other HCWs, flee because they or their families face the prospect of violent death or the threat of widespread violence. Some HCWs leave looking for a stable environment in which they can live and practice their profession safely. Reports indicate that the number of HCWs is exceptionally high among Syrian immigrants [1], with the World Health Organization (WHO) estimating that up to 70% of HCWs have left the country. Beyond those lost to migration, 782 medical personnel were reportedly killed between 2011- 2016 [4]. Because of the falling numbers of skilled medical professionals in Syria, the WHO had voiced concerns early in the conflict regarding the quality of current health services and uncertainties regarding how such medical expertise will be rebuilt.

Another important driver of the health crisis is the socioeconomic challenges that negatively affect HCWs currently operating in Syria. Like most Syrians, many HCWs have lost their property and savings. Moreover, their medical facilities are frequently unable to pay them a salary. Consequently, most are living below the poverty line. This has a marked impact on their ability to work and has forced many of them to accept, often without pay, incredibly challenging working conditions.

Furthermore, the quality of health care provided by the remaining HCWs is questionable since many of them experienced long interruptions to their training programmes, with continuous medical education impossible amidst constant conflict. These insufficiently trained physicians have been obliged to treat medical conditions and perform surgeries for which they lack specialization. This is because of the absence of qualified staff and the continued urgency of the situation. Looking for practical solutions to resume medical training and support the remaining HCWs is an important aspect that needs urgent exploration. Without it, there certainly are negative impacts on the quality of care provided to the Syrian people even after a cessation of conflict [4].

On top of the current situation, what rubs salt into the wound is the spread of Covid-19. The pandemic has created further pressure on Syrian medical staff, who are already exhausted after 10 years of conflict. Over 40,000 cases have so far been detected, and over half of them are in the Northern and North-western parts of the country, areas where health care system has been devastated by direct attacks on hospitals and other health care facilities. Moreover, Coronavirus continues to claim the lives of many Syrian medical staff. For instance, on 16th of February 2021 the Syrian Ministry of health announced that 22 health care providers died due to Covid-19 infection; the actual number could be much higher because of the scarcity of Covid-19 testing.

Despite a continuous deterioration of Syria’s health care system, no actions have been taken to deal with this issue. According to the WHO, more than half of the population in Syria (12 million out of 20 million) require medical attention. Additionally, WHO reported that only 50% of hospitals in Syria are fully functioning, with 25% of hospitals across the country only partially functioning because of a scarcity of medical staff, tools, medications or physical facilities. The remaining 25% are completely out of service. This is the stark reality of the present situation. It is a problem that must be tackled without further delay, because to continue as such will lead only to yet higher rates of mortality and morbidity.

To solve this crisis, several things need to happen. First and foremost, it is important to protect HCWs by enforcing legislation and laws that guarantee their rights and safety, providing them with modern equipment necessary for delivering adequate health care, and attracting them by increasing their salaries. This is the only way to curtail migration of HCWs and to ensure that they are able to practice in a safe work environment.

Second, it is important that the trust between the population and the doctors be restored since the political affiliation of doctors has been a factor affecting the relationship between patients and doctors. For example, patients are reluctant to go to doctors who are known to be part of the opposition because they fear retaliatory persecution by the state in light of the counter-terrorism law passed in July 2012. Therefore, to restore people’s trust, it is crucial to change how belligerents, including the government and the opposition, and individuals look at HCWs and affiliate them with one group or another. This, in turn, is key to increasing the safety of HCW’s.

Third, the international community needs to apply pressure on the Syrian state to force it to respect international humanitarian laws, which sternly prohibits attacks on health care facilities and workers, especially in opposition-held areas. Beyond this, it is also important to support dialogue around protecting health worker and facilities and mechanisms for achieving such protection. Such movements ideally involve civil society leaders, including community and religious leaders, who hold important status in their respective communities and are influential in times of conflict and crisis [5]. In conclusion, the health care system in Syria will continue to deteriorate, perhaps to a point of no return, unless serious actions are taken to ensure the safety and protection of HCWs, their facilities, and their livelihoods.

References

  1. Loss, Julika, Yamen Aldoughle, Alexandra Sauter, and Julia von Sommoggy. 2020. “‘Wait and Wait, That Is the Only Thing They Can Say’: A Qualitative Study Exploring Experiences of Immigrated Syrian Doctors Applying for Medical License in Germany”. BMC Health Services Research 20 (1). doi:10.1186/s12913-020-05209-2.
  2. Omar A. Understanding and Preventing Attacks on Health Facilities During Armed Conflict in Syria. Risk Manag Healthc Policy. 2020;13:191-203
    https://doi.org/10.2147/RMHP.S237256
  3. Bou-Karroum, Lama, Amena El-Harakeh, Inas Kassamany, Hussein Ismail, Nour El Arnaout, Rana Charide, Farah Madi, Sarah Jamali, Tim Martineau, Fadi El-Jardali, and Elie A. Akl. “Health Care Workers in Conflict and Post-conflict Settings: Systematic Mapping of the Evidence.” Plos One 15, no. 5 (2020). doi: 10.1371/journal.pone.0233757.
  4. Omar, Abdulaziz. “Understanding and Preventing Attacks on Health Facilities During Armed Conflict in Syria.” Risk Management and Healthcare Policy Volume 13 (2020): 191-203. doi:10.2147/rmhp. s237256.
  5. Karroum, Lama Bou, Amena El-Harakeh, Inas Kassamany, Hussein Ismail, Nour El Arnaout, Rana Charide, Farah Madi, Sarah Jamali, Tim Martineau, Fadi El-Jardali, and Elie Akl. “Health Care Workers in Conflict and Post-Conflict Settings: Systematic Mapping of the Evidence.” SSRN Electronic Journal, 2019. doi:10.2139/ssrn.3458503.

Doctor Alhouri is a medical doctor. He graduated from the University of Jordan- School of Medicine.

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.

Conflict & Health in the Eastern Mediterranean Series: Lebanon in Ashes: A Looming Mental Health Crisis?

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by Loubaba El Wazir

Beirut, Capital of Lebanon. Photo Source: Flickr, licensed under Creative Commons

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

As Lebanon navigates dark times, the country’s youth struggle to manage their mental wellbeing amid economic and political instability. The country witnessed a nation-wide revolution in October 2019 in reaction to rising taxes and projections of economic collapse. Adding fuel to the fire since has been the banking crisis, the COVID-19 pandemic, and a massive explosion in Beirut in summer 2020. In less than a year, Lebanese youth were left with a devalued national currency, skyrocketing inflation, plummeting job opportunities, and a society poised on the precipice of conflict and self-division.

While there is evidence that riots and protests substantially increase the prevalence of Major Depression and Post-Traumatic Stress Disorder[1], research on the impact of economic and political unrest on mental health in developing countries remains widely unavailable. Our understanding of the latter dynamics could alternatively be informed by the narratives and experiences of mental health practitioners. In our interview*, Dr. Joseph El-Khoury argued that youth are at a high risk of developing mental health disorders in these circumstances due to a fluctuating sense of identity, belonging, and stability. Such issues have already been documented among Arab youth who experienced demographic and political crises[2]. Based on the increasing rates of care seekers, Dr. El-Khoury predicts that if the current state of affairs persists “we could witness more chronic disorders, including depression, anxiety, insomnia, and addiction, affecting an entire generation for the long-term”.

Unsurprisingly, signs of increasing mental health problems have already surfaced. The country’s national suicide hotline managed by Embrace, a mental health non-governmental organisation, has gradually been receiving more calls throughout the crises, with calls rising from 219 in September 2019 to 565 in January 2021. Their last report shows that 58% of these were received from individuals aged 18 to 34 years. One can also observe those struggles first-hand on social media platforms, where Lebanese youth express and share their trauma. Following the Beirut explosion, many tweeted sarcastically about the symbol of Lebanon being a rising Phoenix. Others explicitly denounced resilience, which for them is equivalent to an acceptance of their agonizing reality.

Nevertheless, according to Dr. El-Khoury, the number of people who actually seek professional mental health services reflects a treatment gap. This was previously documented by a national study conducted in 2006 and published in The Lancet, estimating that 89.1% of mental health disorders in Lebanon receive no treatment[3]. Yet, this situation is likely further exacerbated by the economic crisis, which has led most psychologists to raise their fees. Salem, a young Lebanese who struggles with mental disorders, told me that the cost of his sessions has more than tripled since last year, jumping from 75,000 LBP to 250,000 LBP per session. This spike is caused by the banking sector’s loss of liquidity and subsequent devaluation of the national currency. While the central bank of Lebanon continues to peg the Lebanese Pound (LBP) to the USD at 1$= 1515 LBP, banks currently operate at a different exchange rate (1$= 3900 LBP) and the black market has a yet different and constantly fluctuating rate that has reached around 1$= 12,000 LBP in the past couple of months. Given that therapy sessions are priced in USD and psychologists have the freedom to choose which exchange rate to operate with, the range of therapy fees has become vast across clinics, with sessions costing between 150,000 LBP and 800,000 LBP. Not only does this situation restrict the population that is financially capable of accessing mental health care, but it also affects the general public trust in the mental health sector.

The economic crisis has also impacted mental health by diminishing resources that are vital to the sector. The main damage it caused was pushing a big portion of the health workforce abroad. In our interview, Dr. El-Khoury expressed that mental health professionals are “both providers of care and in need of care… socially”, adding that many practitioners are forced to immigrate due to inadequate working conditions and salaries. Moreover, psychiatric medications and comprehensive mental health programs have not escaped the influence of the economic crisis, with many medicines and treatments either completely running out or becoming excessively unaffordable.

This dismal situation leads us to the question of mental health access for Lebanese youth. While many foreign donors, including the United Nations and World Health Organisation, have initiated and contributed to initiatives in Lebanon, these remain limited. Dr. El-Khoury said that although certain non-governmental organisations have programs that offer free therapy sessions, their capacity is likely capped at a couple of thousands of patients. This is certainly inadequate for a population of 6 million Lebanese, 55% of whom are in poverty, and more than 50% of whom have no formal health insurance coverage. Among those who do enjoy health insurance, a very small minority get their psychologist sessions covered, given that most insurance programs only cover psychiatric, but not psychological, therapy. The National Social Security Fund plans to incorporate partial coverage for these sessions soon, according to Rabih El Chammay, head of the National Mental Health Programme. Yet, little is to be expected, given that the institution is “broke” and has a history of fragile implementation.

The ability of Lebanese youth to re-establish their mental health well-being following the recent catastrophes seems to be inextricably dependent on political, economic, and institutional reform. Particularly, it is essential to establish a rigorous national mental health system that is funded and organised by the health branch of the Lebanese government. Given that this seems like a distant prospect, it is crucial for mental health organisations to coordinate efforts across the country to ensure accessible care for the most vulnerable. Yet, we should be cautious about claiming that the NGO sector can manage this crisis alone, an idea which, in the words of Dr. El-Khoury, “washes the government’s hands from providing sustainable, free, or at least low-cost services”.

The same oligarchy that murdered and terrorised thousands of families in the 1975 Lebanese Civil War is largely responsible for the economic and social collapse happening now. While strengthening the mental health system is essential to lessen the collective psychological impact of the crisis, what the small Mediterranean country ultimately needs is political reform and accountability, now more than ever.

[1] Ni, Michael Y., Yoona Kim, Ian McDowell, Suki Wong, Hong Qiu, Irene OL Wong, Sandro Galea, and Gabriel M. Leung. “Mental health during and after protests, riots and revolutions: a systematic review.” Australian & New Zealand Journal of Psychiatry 54, no. 3 (2020): 232-243.

[2] Mulderig, M. C. (2013). An uncertain future: Youth frustration and the Arab Spring.

[3] Karam, Elie G., Zeina N. Mneimneh, Aimee N. Karam, John A. Fayyad, Soumana C. Nasser, Somnath Chatterji, and Ronald C. Kessler. “Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey.” The Lancet 367, no. 9515 (2006): 1000-1006.

Loubaba is an MSc. Social and Cultural Psychology student at the London School of Economics and Political Science. She holds a Bachelor in Psychology from the American University of Beirut. She was involved in the Lebanese October 17 Revolution and has an interest in its impact on Lebanese society. Loubaba has completed internships at the Issam Fares Institute for Public Policy and the United Nations ESCWA.

Conflict & Health in the Eastern Mediterranean Series: Medical Education under blockage, protected conflict, and constant warfare

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by Alaa M. Ismail

5th year medical students at the Islamic University of Gaza practicing in the suturing-skill lab

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

Gaza Strip, a densely occupied territory where the majority are concentrated in refugee camps and living under austere conditions, has exceeded two million residents in 2020. Decades of protracted conflict, years of blockade, and deep poverty have caused profound suffering in Gaza. The local economy has witnessed multiple, recurrent crises with 53% of people falling below deep poverty line, more than half of residents registering as unemployed in 2019 and most of residents being dependent on humanitarian aid from national and international organizations. Such conditions have hindered normalcy in all aspects of life, particularly the educational process.

Although Gaza enjoys one of the highest literacy rates in the world, with a rate of 99.5% among college-age group in 2019, the educational process, in schools and universities, faces enormous difficulties. Since 2007, the government has rarely paid full salaries to workers in the public sector, including teachers, which has had deleterious effects on living conditions in general, and on education provision in particular. Students coming from families whose breadwinner is a public employee have struggled to access higher education due to financial limitations. The dropout rate jumped from 40% in 2018-2019 to 70% in 2019-2020 among postgraduate students as reported by Al-Mezan Center for human rights in Gaza.

High rates of unemployment and political instability have caused dire economic situations. Palestinian families in Gaza find themselves overwhelmed with their children’s basic needs such as books, stationery tools, and daily expenses. This has led to preferential gender treatment as many parents consider early marriage, which is relatively high in Gaza, for young female family members as a way to relieve themselves of the financial burden of education. As for males, it has also meant undertaking cheap, unregulated labour to escape from financial hardships whilst studying.

Turning to medical education, a large number of young doctors have quit their jobs and left Gaza to seek better opportunities. Gaza lacks proper educational hospitals, instead, all medical students and residents are trained in public hospitals. Consultants at those hospitals have to manage being full-time doctors serving in the hospital while taking on educational duties as well. This pushes graduates to seek better opportunities abroad. There is no available published data on the exact number of migrant doctors, but it has been an increasingly common occurrence over recent years.

The educational sector has also been damaged due to repetitive attacks under Israeli occupation. For example, the Islamic University, where I work, was directly targeted both in 2008 and in 2014. The science building, which includes all labs in the university, was completely destroyed in 2009 and was completely non-functional until 2020. Even though the building has been rebuilt, the devices and material needed to run the labs were either severely delayed or not permitted to enter Gaza for months by the Israeli authorities. During this troubled period, students in scientific colleges were obliged to study only the theoretical aspects of a subject without any lab-based training.

Another way in which the educational process is impeded are the travel restrictions facing residents of Gaza. Students in Gaza who have opportunities abroad have to go through a long process to obtain the required security permit in order to travel. Such security processes, the seemingly arbitrary delays, and rejections of permits make it nearly impossible for those planning to attend conferences or training courses. Moreover, students travelling to attend undergraduate and postgraduate courses abroad spend their entire study period without returning home because of the fear that they will not be able to obtain the required security permits if they came back to visit.

Challenges in learning and education processes have markedly increased with the emergence of the Covid-19 pandemic. The Ministry of Education has withheld all face-to-face activities since the 5th of March for fear of spreading the infection among students and has started using exclusively virtual methods to continue the education process. The new advent of E-learning has proven a significant hurdle for both lecturers and students, primarily as we did not experience it in our medical education and we have limited proficiency in online learning platforms and technologies. Beyond this, chronic electricity shortages continue to distress students and doctors. One the one hand, electricity cuts affect the work flow in hospitals. On the other, many students have had to miss online sessions and exams due to electricity cuts. Alongside electricity shortages, the needs for a personal computer for each student to attend online classes is impossible to meet for families in Gaza. As one study found, with large families crowded into small houses, most find it exceedingly hard for their children to keep up with online education.

Formidable obstacles face Gaza residents as pressure mounts from years of siege, rampant poverty, unemployment and poor health and economic circumstances. The educational sector, especially medical education, bears the brunt of those obstacles. Yet, students and teachers, especially in the health sector, in Gaza continue to prioritize education in the hope of brighter future.

Alaa is a Board-certified Obstetrician and Gynaecologist. She is the Obstetrics and Gynaecology department head at the Islamic University of Gaza. She is active as a women’s health advocate and medical educator. Learn more about Alaa at her LinkedIn Profile.