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Series on Women and Children’s Health in Conflict - Maternal and Reproductive Health in the Gaza Strip: the impact of years of blockade and conflict

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A Palestinian woman holds her baby in one of the UNRWA school shelters in the Gaza Strip during Operation Protective Edge in the summer of 2014, Photo by UNRWA.

This article is part of the Strife Series on Women and Children’s Health in Conflict. Read the Series Introduction at this link.

Over two million Palestinians in the Gaza Strip live in degrading conditions of poverty, food insecurity, and high unemployment. In June 2007, Israel imposed a land, sea, and air blockade on the Gaza Strip, and since 2008, Israeli military forces have mounted several operations against the Strip. Years of blockage compounded by military interventions have led to ruinous consequences on the healthcare system. While reports by health organizations and media outlets focus disproportionately on the numbers of casualties, deaths, and long-term disabilities, much less attention is paid to the conflict’s impact on maternal and reproductive health services.

Since the start of the blockage, the healthcare system in the Gaza Strip has been suffering from a significant shortage of essential services, with maternal and child healthcare services being affected the worst. Mothers and their babies are often discharged early (within 2-3 hours) due to the limited capacity and high demands for healthcare facilities. The quality of maternal services is also compromised due to the high number of deliveries and increasing rates of caesarean section, which further increase the burden on healthcare workers in the field. While the total fertility rate has declined in the occupied Palestinian Territory, it is still one of the highest in the region. At any given time, there are about 45,000 pregnant women in the Gaza Strip.

The large number of pregnancies in Gaza can be attributed to the uneven and relatively poor access to family planning services. Indeed, women in lower socioeconomic brackets who live in remote and disadvantaged regions are less likely to benefit from them. The unmet need for family planning increases the number of unwanted pregnancies, and therefore, increases the risk of unsafe abortions and maternal complications. According to a family health survey in 2010, high unmet needs for family planning was associated with 30% of unwanted pregnancies. In 2019, two out of the five essential family planning methods (male condoms and progesterone-only pills) have been at zero stock level (available for less than a month) at the United Nations Relief and Works Agency (UNRWA) and Ministry of Health (MoH) clinics in the Gaza Strip.

Maternal pharmaceuticals have also been affected by the blockade. For example, iron (a drug used to treat anaemia) and folic acid (a drug used to prevent a certain type of congenital defects) have been severely limited. In 2018, according to the MoH in Gaza, nearly 40% of pregnant women were anaemic. Although several organisations have supported the provision of life-saving maternal health drugs, 70% of essential maternal and child health drugs remain at zero stock in the MoH. In a mapping study done by the United Nations International Children’s Emergency Fund (UNICEF), all assessed primary healthcare (PHC) facilities reported that essential pharmaceuticals and life-saving drugs were either unavailable or had been experiencing interrupted supply for the last six months. These include iron, folic acid, antibiotics, and methyldopa (a drug used to treat high blood pressure during pregnancy).

Year on year, maternal and reproductive health in Gaza becomes increasingly concerning. A 2019 situation report by the World Health Organisation (WHO) showed that maternal deaths increased by 122% between 2017-2018 (from 8.6 to 19.1 per 100,000 live births), and of these, 63% occurred before childbirth. Several factors can be attributed to this increase. One of these is poor PHC. PHC staff have limited training, and according to the UNICEF report, preconception care (care before the pregnancy) guidelines were not available at any of the assessed PHC centres. The same report also showed that all the interviewed pregnant women were not aware of danger signs during pregnancy.

There is no doubt that the decline in healthcare standards is more significant during and following major military operations: women become unable to access maternal and reproductive healthcare services, and medical resources become incredibly scarce. In July 2014, the Gaza Strip experienced a 51-day military operation (Protective Edge) by the Israeli military, one of four major military operations since 2009. Nearly the entire population in Gaza was involved in the conflict and was affected by the concurrent destruction of infrastructure. The impact of Protective Edge on women specifically was huge. The UN-Human Rights Council (UNHRC) reported that 299 women were killed and 3,540 others were injured. The UN Office for the Coordination of Humanitarian Affairs (OCHA) reported that over 40,000 pregnant women were unable to access essential maternal healthcare, and accordingly, the neonatal mortality rate doubled from 7% to 14%.

The inability to access healthcare services can be attributed to two main factors. First, many healthcare facilities were damaged, and the remainder were overwhelmed. During the crisis, only 50% of PHC centres were operating, leading to a significant decline in accessing family planning services. Moreover, 17 hospitals were put out of action, and six maternity wards were closed. The high number of casualties meant some remaining wards (including maternity units) were adapted into surgical wards. Thus, women were subject to low levels of care and were discharged early after delivery, resulting in a massive deterioration of their health.

Secondly, there was a near lack of capacity and preparedness to respond to the needs of internally displaced persons (IDPs). OCHA reported that half a million people (28% of the population) were internally displaced in schools and informal shelters which were not equipped to provide maternal and reproductive health services. Throughout the military operation, women who needed these services were instead referred to outside facilities during a time when transportation was severely restricted and highly dangerous even to ambulances. Furthermore, pregnant and lactating women had reduced access to special dietary support and vitamin supplements. The overcrowded shelters, where multiple families had to stay in the same room, were particularly challenging for women due to the lack of privacy and female hygiene products.

In addition to the effect of the blockade and the repetitive military operations on providing essential healthcare services for women, the Great March of Return (GMR) also had significant impacts. The GMR, which catalysed on March 30th 2018, sought to end the Israeli’s illegal blockade on the Gaza Strip. In doing so, however, it has added extra pressure on the already overwhelmed healthcare system. The massive influx of casualties led to the suspension of elective surgeries and the reallocation of hospital beds to serve the injured patients.

About six months after the start of the GMR, the US Trump administration decided to cut off the American financial assistance to the UNRWA. UNRWA plays a vital role in the Gaza Strip’s health sector, delivering free PHC services through 22 facilities. UNRWA clinics serve about 70% of the Palestinian population in the Gaza Strip, providing them with essential antenatal and postnatal healthcare services. In 2018, 39,709 pregnant women attended PHC facilities at the UNRWA. This reflects the tremendous effect of the withdrawal of US financial support on the quality of maternal and reproductive health services in the Gaza Strip.

Maternal and reproductive health in the Gaza Strip is on the edge of the abyss. There is an urgent and immediate need to ease the blockade and improve maternal healthcare infrastructure, both by opening new facilities and increasing medical staff’s capacity. A holistic emergency plan, which prioritises womens’ needs and rights, is indispensable and should be adopted. Every woman has the right to receive full and high-quality maternal and reproductive health services, even during emergencies. Good womens’ healthcare is critical to maintaining a healthy life for every Palestinian in the Gaza Strip. The Palestinian society will not be safe unless Palestinian women are safe.

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.

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.

Gaza, Israel, and Netanyahu’s Latest Coalition Crisis

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By Lauren Mellinger

21 December 2018

Israeli Prime Minister Benjamin Netanyahu wants to avoid an early election for fear that he might lose due to the public’s displeasure with his handling of the Gaza crisis. (Photo credit: David Shankbone)

 

This past tumultuous month in Israeli politics challenged two key assumptions about Israel’s long-serving prime minister Benjamin Netanyahu. First, despite speculation in recent months that the Netanyahu-era is drawing to a close, it is certainly not over yet. Perhaps of greater significance is the second element to emerge from last month’s political crisis: Israel’s ‘Mr. Security’ — who recently said that ‘[t]here is no diplomatic solution to Gaza’ and compared Hamas to ISIS — is not going to topple Hamas in Gaza.

How Gaza precipitated Israel’s latest domestic political crisis

In November Israel and Hamas reached a ceasefire. Pursuant to the terms of the agreement, Qatar agreed to provide $90 million in cash to Gaza over the next six months, along with an immediate infusion of fuel into the Strip. The initial $15 million instalment was paid out to Palestinian civil servants in the Gaza Strip on November 11 and served to further bolster Hamas amongst its Gaza-based supporters. The deal was controversial for several reasons: first, whereas Israel has periodically allowed Gulf States to transfer materials for civilian projects and fuel to Gaza, it typically rejects cash donations due to concerns that it would reach Hamas militants. Hamas’s Gaza-based leader Yahya Sinwar responded to the first cash delivery by publicly allying himself with Hamas’s military wing. It is also noteworthy that Israel approved the terms despite having long regarded Qatar as a ‘terror-supporting state.’ Lastly, the move was heavily debated within the security cabinet, but was not coordinated with the Palestinian Authority, suggesting that the Netanyahu government was seeking some form of long-term compromise with Hamas in Gaza, despite a long history of stating the opposite.

Then the political crisis began. Shortly after images of the first suitcases of Qatari cash entering Gaza went public, news broke of a botched IDF raid near Khan Younis, followed by a 48-hour barrage of rockets from Gaza — for which Hamas claimed responsibility. Defence Minister Avigdor Lieberman resigned, and withdrew his party from the coalition — arguing that the ceasefire, together with the Qatar arrangement, was ‘capitulating to terror.’ Then, Education Minister and Jewish Home Party leader Naftali Bennett threatened to quit the coalition unless he were assigned the defence portfolio. Given the likelihood that Netanyahu would reject Bennett’s ultimatum, both right and left-wing parties began to call for new elections.

As Israel’s government teetered on the brink of collapse, Netanyahu once again shrewdly outmanoeuvred his political rivals. Speaking from the Defence Ministry — a portfolio which Netanyahu currently holds, as well as that of prime minister and foreign minister — he rejected calls for new elections stating, ‘We are in the middle of a military campaign, and you don’t abandon a campaign to play politics.’ In an embarrassing about-face the following morning Bennett announced he would remain in the coalition — reneging on his prior ultimatum.

Though Kulanu leader and current Finance Minister Moshe Kahlon signalled to his faction that they should prepare for early elections, he too has not yet resigned from the government. For now, Netanyahu’s coalition stands with a fragile 61-seat majority.

Why delay early elections?

Early elections are routine in Israel’s domestic politics. In the 70 years since the country’s founding not one government has completed a full term. The current prime minister himself has engineered conditions for snap elections on more than one occasion. While it appeared that early elections seemed inevitable following Lieberman’s resignation, Netanyahu acted swiftly, doing everything possible to delay them.

Growing dissatisfaction with Netanyahu’s Gaza policies left him open to a challenge by both the right-wing parties within his coalition, and the public. This latest political crisis had Netanyahu challenged by junior coalition partners from his right, and specifically on matters of national security. Netanyahu has long proclaimed himself to be the best protector of Israel’s security. Indeed his campaign slogan in the 2015 elections translates to ‘Only the Likud — Only Netanyahu.’ New elections under such circumstances would have forced Netanyahu to face his ‘worst-case election scenario.’

Public opinion was also a critical factor in Netanyahu’s efforts to avoid early elections. Following the events last month, polls showed that 74 percent of Israelis were dissatisfied with Netanyahu’s performance in the Gaza crisis. Likud remained in the lead in most polls, albeit with a record-low 29 seats — a significant drop from August 2018, when Netanyahu told a Likud faction that he anticipated winning between 35 and 40 seats in the next elections. Furthermore, by holding onto the defence portfolio, at least for now, Netanyahu made himself vulnerable to criticism by becoming the main target for the public’s outrage. This was evident from demonstrations in southern towns bordering Gaza, as well as outside of the defence ministry in Tel Aviv following Lieberman’s resignation, where protestors shouted ‘Bibi go home!’ among other slogans expressing disapproval with the prime minister’s Gaza policies.

Can Israel’s ‘Mr. Security’ win another term?

With Israel heading into a definite election year, all politicians are officially in campaign mode. It is highly unlikely that this government will continue until November 2019, when elections are scheduled to be held. For the moment, if everything is held constant, the Likud remains in the lead to net the most seats in the next election. As political consultant Mitchell Barak remarked, ‘[Netanyahu’s] got no competition. . . He’s running against himself.’ Yet, the polls referenced above did not take into account the prospect of a viable centre or centre-left bloc forming ahead of the elections. Nor did they account for the likelihood that former IDF Chief of Staff Benny Gantz will announce a new party. Though Gantz’s party may not be able to surpass Likud in the next elections, it is expected to chip away at Likud’s lead.

Furthermore, it remains to be seen whether Netanyahu’s efforts to outmanoeuvre his rivals did more to damage them electorally, than him. Shortly after the crisis was resolved, a poll found that 58 percent of Israelis did not believe Netanyahu’s claims that the government should not be brought down at present due to a ‘sensitive security situation’ for which he provided no further explanation. This is compared with only 31 percent who felt his concerns for Israel’s national security were genuine.

In a region with countless hostile adversaries popping up like a never-ending game of whack-a-mole, Netanyahu’s reputation as ‘Mr. Security’ is a high bar to uphold. The public’s disapproval of his latest Gaza policies however, should be understood in the broader context. Despite a history of brash public statements calling for a tough response to Hamas, and terrorism in general, and having criticised his predecessors in office on numerous occasions for their handling of Hamas and Gaza, his actions in office indicate that he is risk-averse — in particular when it comes to employing military force, and is reluctant to commit to putting boots on the ground in Gaza. His past public statements stand in marked contrast to his actions in recent weeks, including working towards a ceasefire and allowing an influx of Qatari cash. Thus it is hardly surprising that residents of Gaza-border communities — a core base of Likud voters — and several of his coalition partners spent much of the past few weeks accusing him of being ‘weak’ on Gaza.

Moreover, in recent weeks Netanyahu has struggled to restore the public’s faith in his reputation as ‘Mr. Security.’ A Tel Aviv University poll earlier this month found 76 percent of Jewish Israelis thought that Netanyahu failed when dealing with Hamas. The increase in terror attacks in the West Bank in recent weeks has renewed protests against Netanyahu — once again, from members of his base, challenging his recent decisions regarding Gaza. Despite the recently launched Operation Northern Shield’s initial successes in uncovering Hizballah-built tunnels under the Israel-Lebanon border, many have raised questions as to whether the timing of the operation was politically motivated, in light of the hit to his reputation Netanyahu has experienced in recent weeks, and with the prospect of indictments hanging over his head.

Though polls indicate that Netanyahu averted the prospect of early elections for now and has, for the moment, avoided a referendum on his handling of Gaza, the situation with Hamas in both Gaza and the West Bank has yet to be stabilised. Furthermore, it is unclear to what extent Netanyahu can proceed with the arrangements with Qatar, absent broader public support. It remains to be seen whether Israel’s ‘Mr. Security’ can prevail in the next elections, or whether Netanyahu has run out of political life lines.

Lauren Mellinger is a doctoral candidate in War Studies at King’s College London and a 2018-19 Israel Institute Doctoral Fellow. She is also a former senior editor of Strife’s blog and journal. Her research specializes in Israeli counterterrorism, foreign policy, and national security decision-making, as well as the Israeli-Palestinian conflict. You can follow her on Twitter @Lauren_M04.

Image source: https://commons.wikimedia.org/wiki/File:Netanyahu_campaign_posters_in_Jerusalem.jpg