Occupation is a Public Health Crisis Too

Anurima Kumar and Meera Rothman

In the face of the glaring humanitarian crisis in Palestine, the silence of American public health institutions has been deafening. After a month of relentlessly bombing Al-Shifa hospital (notably using American missiles that slice through flesh), Israeli troops entered and raided the hospital wards, killing and displacing people in need of immediate care.^[1] The American Medical Association (AMA), widely recognized as the foremost medical lobbying group in the nation, shut down a resolution that supports a ceasefire in Gaza and insisted that war discussion is not appropriate for their organization.^[2] Yet just a year ago, the AMA called for an immediate ceasefire in Ukraine.^[3] In early November, with the Palestinian death count at 9,448, the American Public Health Association condemned Hamas’s attack on Israel and urged for safety for all people, with no mention of the ongoing systematic mass murder of Palestinians.^[4] One week later they issued a one-sentence statement calling for a ceasefire in Gaza.^[5] The Palestinian death count on 20 November was 13,215.^[6]

Social determinants of health are the conditions in which people are born, grow, live, and age that shape their health.^[7] Determinants—such as access to clean water and healthy food—are directly influenced by structural policies, government, and war. They speak to a fundamental truth: health is political. As public health practitioners, we understand the social construction of health as well as the equal and inherent value of all life. Palestinians’ health—like everyone’s health—is not disposable. Power and money dictate which bodies are deemed worthy of life and which lives are deemed worthy of health.

When the US government funds and allies itself with one of the most intense bombing campaigns in history, this directly implicates Americans and our work.^[8] The repression, blockading, displacement, and collective punishment of stateless people, with US support, is a public health issue.^[9] Health and medical institutions have no problem naming racial health inequity in the American system, but cannot name the more obvious construction of health by Israeli apartheid, occupation, and siege. In the name of upholding public health values it is imperative that American health and medical institutions publicly call for an immediate ceasefire, an end to US aid to Israel, and an end to the Israeli occupation of Palestine.

The public health crisis in Gaza began more than 75 years ago. Israeli occupation and forced Palestinian displacement have affected every aspect of life in Gaza. During the Nakba in 1948, Israel forcefully displaced 700,000 people, many of whom fled to Gaza.^[10] Commonly called an “open-air prison,” Gaza holds two million Palestinians in a 139 square mile area, making it one of the most densely populated areas in the world.^[11] Israel, the warden, prevents people from leaving by banning free movement, limiting work permits outside the gates, and conducting abusive checkpoint searches.^[12]

Overcrowding is a significant contributor to numerous health issues, such as cancer, chronic obstructive pulmonary disease, cardiovascular disease, and asthma.^[13] Overcrowded areas suffer from higher rates of infectious diseases, including tuberculosis and COVID-19.^[14] Children who grow up in these areas have low cognitive development, high blood pressure, and poor respiratory health.^[15] In Gaza, nearly 50% of the population are children, and 22 out of 1,000 of those children die before their fifth birthday, a rate five times higher than for children in neighboring Israel.^[16] Indeed, even before the onset of this most recent wave of state violence, research has shown that civilian health in Gaza is widely impacted by these conditions of density.

For 75 years, Israel has been waging urbicide, the intentional destruction of cities, as a tactic of control.^[17] Long-term destruction of the physical environment has contributed to the degradation and loss of social and cultural networks, bringing with it collective psychological vulnerability and the sense of impermanence.^[18] Israel has admitted to herbicidal warfare, or clearing arable land by spraying crop-killing herbicides.^[19] Green spaces are valuable in crowded areas to negate heat, facilitate social interaction, and allow for physical activity.^[20] Herbicidal warfare and urbicide limit all of these benefits and severely harm air quality, further damaging respiratory health in Gaza. This is an environmental justice issue.

The scarcity of food, water, and electricity throughout the 17-year siege on Gaza have had devastating consequences for Palestinian nutrition. Israel’s herbicidal warfare has eradicated 42% of cultivable land in Gaza, exemplified by the 112,000 olive trees that Israel destroyed between 2000 and 2008.^[21] One-third of the farmland in Gaza is in “no-go” zones that Palestinians are barred from entering. Israeli food blockades limit baby formula, wheat, rice, chocolate, cattle, and more, from entering Gaza.^[22] These multi-pronged strategies to limit access to healthy food have direct consequences: within one year, child malnutrition doubled in Gaza solely as a result of the blockades.^[23] Child malnutrition has long-term health effects including weakened immune systems and neurodevelopmental deficits.^[24] The UN has deemed Gaza ‘unlivable’ because of the lack of clean water, and at least 25% of disease in Gaza result from the poor water quality or lack of access to water.^[25] These diseases—acute hepatitis A, typhoid fever, acute diarrhea, and viral meningitis—endanger the lives of newborns and infants especially.^[26]

In 2017, Israeli blockades limited electricity in Palestine to only 2-4 hours per day.^[27] Under these conditions, medical procedures cannot be conducted for most of the day, leading to countless preventable deaths. Over two-thirds of the people of Gaza are registered with refugee statuses.^[28] This poses diverse negative health outcomes and leaves people at high risk of post-traumatic stress disorder (PTSD).^[29] Even the concept of PTSD is insufficient, as for Gazans, the trauma is ongoing. Palestinians in Gaza more accurately endure continuous trauma stress (CTS), a distinct diagnosis from PTSD.

Now, a decades-long health crisis has escalated to an acute emergency defined by mass death and privation. Since the state of Israel began its campaign of collective punishment in Gaza and the West Bank in October over 13,000 Palestinians have been killed, including over 5,500 children.^[30] A novel term has emerged: Wounded Child No Surviving Family (WCNSF).^[31] Israel’s use of illegal white phosphorus has been especially brutal, burning skin down to bone and causing multiple organ dysfunction for anyone who comes into contact with munition fragments.^[32] Around 50,000 Palestinians in Gaza are currently pregnant, malnourished, and have nowhere safe to give birth, no anesthetics, and no postpartum care for stress-induced miscarriages.^[33] Even ignoring the lack of basic care, this is a reproductive justice emergency nestled within a larger humanitarian crisis.

For Palestinians in Gaza who are not killed or injured by direct violence, Israel has cut off all necessary conditions for life. Palestinians in Gaza are now living on two pieces of bread per day.^[34] After Israel destroyed all bakeries, flour mills, and water access, Gazans are living on barely any food and water.^[35] Every night, children in Gaza sleep hungry, under the constant buzz of military drones.^[36] A lack of fuel has shut down all desalination plants, forcing Gazans to drink brackish seawater, and an imminent threat of cholera.^[37] Infectious diseases are spreading rapidly: 70,000 upper respiratory infections, 44,000 counts of diarrhea, 12,635 skin rashes, 8,944 scabies and lice, and 1,005 cases of chickenpox.^[38]

Medical workers and health professionals are, by and large, respected across cultures as moral voices invested in life, health, and welfare. In this moment of crisis, we must show ourselves to be worthy of this authority. The Israeli occupation and the military campaign to cleanse the land of Palestinians have led to a public health disaster. Public health institutions, workers, and students must call for a ceasefire in Gaza now and stand with Palestinians in asserting their right to life, health, clean air, nutrition, and to live freely on their land.

Anurima Kumar, MPH in Sociomedical Sciences, email anurimavk@gmail.com

Meera Rothman, MSc in Health Policy, Planning, and Financing, email rothmanmeera@gmail.com

[1] PressTV. “US Hellfire Missiles Used to Strike Gaza Al-Shifa Hospital: Sources.” PressTV, November 12, 2023; Al Jazeera. “Thousands Trapped as Israeli Forces Raid Gaza’s al-Shifa Hospital.” November 15, 2023, https://www.aljazeera.com/news/2023/11/15/israeli-forces-raid-gazas-al-shifa-hospital-in-targeted-operation.

[2] S. Firth, “AMA Declines to Debate Resolution on Israel-Hamas Conflict.” Medical News, November 12, 2023. https://www.medpagetoday.com/meetingcoverage/ama/107302.

[3] G. Harmon, “Targeting Civilians and Health Care in War Is Unconscionable.” American Medical Association, April 8, 2022. https://www.ama-assn.org/about/leadership/targeting-civilians-and-health-care-war-unconscionable.

[4] M. Gadzo and V. Pietromarchi. “Israel-Hamas War Updates: Another Gaza School Hit by Heavy Israeli Bombing.” Al Jazeera, November 19, 2023. https://www.aljazeera.com/news/liveblog/2023/11/4/israel-hamas-war-live-20-dead-in-israeli-attack-on-school-ministry; “Public Health Implications of the Israel-Hamas War.” American Public Health Association News Releases. Accessed November 20, 2023. https://apha.org/News-and-Media/News-Releases/APHA-News-Releases/2023/Public-Health-Implications-of-the-Israel-Hamas-War

[5] S. Firth, “Apha Urges Biden to Call for Immediate Ceasefire in Israel-Hamas Conflict.” Medical News, November 17, 2023, https://www.medpagetoday.com/publichealthpolicy/publichealth/107429.

[6] AJLabs. “Israel-Gaza War in Maps and Charts: Live Tracker.” Al Jazeera, November 20, 2023. https://www.aljazeera.com/news/longform/2023/10/9/israel-hamas-war-in-maps-and-charts-live-tracker.

[7]  “Social Determinants of Health.” Social Determinants of Health, n.d. https://health.gov/healthypeople/priority-areas/social-determinants-health.

[8] H. Duggal and A. Shakeeb. “Israel’s Attacks on Gaza: The Weapons and Mapping the Scale of Destruction.” Al Jazeera, November 11, 2023. https://www.aljazeera.com/news/longform/2023/11/9/israel-attacks-on-gaza-weapons-and-scale-of-destruction.

[9]  A. Barros. “Is There a Path to Refugee Resettlement for Palestinians?” Voice of America, October 28, 2023. https://www.voanews.com/a/is-there-a-path-to-refugee-resettlement-for-palestinians-/7330124.html#:~:text=27%2C%202023.&text=Palestinians%20are%20the%20largest%20stateless,are%20a%20product%20of%20conflict.

[10] K. Bshara, “Architecture and Urban Planning in Palestine.” palquest, January 2, 1970. https://www.palquest.org/en/highlight/10514/architecture-and-urban-planning-palestine.

[11]  A. S.  Muhaisen, S. Ahmed. “Development of the House Architectural Design in the Gaza Strip.” Athens Journal of Architecture, 2, no. 2 (2016): 131–50. https://doi.org/10.30958/aja.2-2-3.

[12] West Bank and Gaza 2022 human rights report – U.S. department of State. Accessed November 21, 2023. https://www.state.gov/wp-content/uploads/2023/03/415610_WEST-BANK-AND-GAZA-2022-HUMAN-RIGHTS-REPORT.pdf.

[13] E. R. Carnegie, I. Greig, A. Taylor, A. Bak-Klimek, and O. Okoye. “Is Population Density Associated with Non-Communicable Disease in Western Developed Countries? A Systematic Review.” International Journal of Environmental Research and Public Health 19, no. 5 (2022): 2638. https://doi.org/10.3390/ijerph19052638.

[14] R. Aldridge and W. Robert. “Household Overcrowding and Risk of SARS-COV-2: Analysis of the Virus Watch Prospective Community Cohort Study in England and Wales.” Wellcome Open Research 6 (December 15, 2021): 347. https://doi.org/10.12688/wellcomeopenres.17308.1. 

[15]  E. Burton, “The Importance of the Built Environment to Children’s Well-Being: What do we know?” Cities, Health and Well-Being. Accessed November 21, 2023. https://lsecities.net/wp-content/uploads/2011/11/2011_chw_4050_Burton.pdf.

[16] T. Waterston and D. Nasser. “Access to Healthcare for Children in Palestine.” BMJ Paediatrics Open 1, no. 1 (2017). https://doi.org/10.1136/bmjpo-2017-000115.

[17] D. Golańska, “Slow Urbicide: Accounting for the Shifting Temporalities of Political Violence in the West Bank,” Geoforum 132 (2022): 125–34. https://doi.org/10.1016/j.geoforum.2022.04.012; M. Coward, Urbicide: The politics of urban destruction. London: Routledge, 2010

[18] K. Mezentsev, “Urbicide, Everyday Life and Post-War Urban Healing.” EUniWell Open Lecture Series. Lecture presented at the EUniWell Open Lecture Series, June 15, 2023.

[19] “Herbicidal Warfare in Gaza.” Forensic Architecture. Accessed November 20, 2023. https://forensic-architecture.org/investigation/herbicidal-warfare-in-gaza.

[20]  A. Lee, H. Jordan, and J. Horsley. “Value of Urban Green Spaces in Promoting Healthy Living and Wellbeing: Prospects for Planning.” Risk Management and Healthcare Policy, 2015, 131. https://doi.org/10.2147/rmhp.s61654.

[21] “The Olive Branch Fights Back.” Inter Press Service, January 9, 2012. https://reliefweb.int/report/occupied-palestinian-territory/olive-branch-fights-back.

[22] A. Gross and T. Feldman. “‘We Didn’t Want to Hear the Word “Calories”’: Rethinking Food Security, Food Power, and Food Sovereignty—Lessons from the Gaza Closure.” Berkeley Journal of international Law, 6, 33, no. 2 (2015); Middle East Monitor. “Lack of Medicated Baby Formula Puts Life of Gaza Children at Stake.” Middle East Monitor, January 8, 2019. https://www.middleeastmonitor.com/20190108-lack-of-medicated-baby-formula-puts-life-of-gaza-children-at-stake/; A. Renton, “No Gourmets in Gaza.” The Guardian, June 16, 2009.

[23] C. Dyer, “Cases of Child Malnutrition Double in Gaza Because of Blockade.” BMJ 324, no. 7338 (2002): 632–632. https://doi.org/10.1136/bmj.324.7338.632.

[24] J. R. Galler, M. L. Bringas-Vega, Q. Tang, et al. “Neurodevelopmental Effects of Childhood Malnutrition: A Neuroimaging Perspective.” NeuroImage 231 (2021): 117828. https://doi.org/10.1016/j.neuroimage.2021.117828.

[25]  “Gaza ‘Unliveable’, UN Special Rapporteur for the Situation of Human Rights in the OPT Tells Third Committee – Press Release (Excerpts) – Question of Palestine.” 73^rd session, 31st and 32^nd meetings, October 24, 2018. https://www.un.org/unispal/document/gaza-unliveable-un-special-rapporteur-for-the-situation-of-human-rights-in-the-opt-tells-third-committee-press-release-excerpts/.

[26] Humanitarian bulletin occupied palestinian territory, 2018. https://www.ochaopt.org/sites/default/files/hummonitor_october_2018.pdf.

[27] S. McCloskey, “UN’s Warning That Gaza Will Not Be a ‘Liveable Place’ by 2020 Has Been …” openDemocracy, January 15, 2020. https://www.opendemocracy.net/en/north-africa-west-asia/uns-warning-that-gaza-will-not-be-a-liveable-place-by-2020-has-been-realised/.

[28] N. Citino, A. Martín Gil. “Generations of Palestinian Refugees Face Protracted Displacement and Dispossession.” Migration Policy Institute, May 3, 2023. https://www.migrationpolicy.org/article/palestinian-refugees-dispossession.

[29] Refugee and migrant health, May 2, 2022. https://www.who.int/news-room/fact-sheets/detail/refugee-and-migrant-health.

[30]  AJLabs. “Israel-Gaza War in Maps and Charts: Live Tracker.” Al Jazeera, November 20, 2023. https://www.aljazeera.com/news/longform/2023/10/9/israel-hamas-war-in-maps-and-charts-live-tracker.

[31] N. Doukhi, “In Gaza, Children Pay a High Price for Israeli Retaliation.” L’Orient Today, October 20, 2023. https://today.lorientlejour.com/article/1354070/in-gaza-children-pay-a-high-price-for-israeli-retaliation.html.

[32] P. Slibert and M. Ristic. “Israel/OPT: Identifying the Israeli Army’s Use of White Phosphorus in Gaza.” Israel/OPT: Identifying the Israeli army’s use of white phosphorus in Gaza, October 13, 2023. https://citizenevidence.org/2023/10/13/israel-opt-identifying-the-israeli-armys-use-of-white-phosphorus-in-gaza/.

[33]  C. Paccalin, “Malnourished, Sick and Scared: Pregnant Women in Gaza Face ‘Unthinkable Challenges.’” France 24, November 6, 2023. https://www.france24.com/en/middle-east/20231106-malnourished-sick-and-scared-pregnant-women-in-gaza-face-unthinkable-challenges.

[34]  E. M. Lederer, “The Average Palestinian in Gaza Is Living on 2 Pieces of Bread a Day, UN Official Says.” AP News, November 4, 2023. https://apnews.com/article/gaza-humanitarian-un-bread-water-unrwa-fuel-90fcfc40d63f8604d0effa861e793c89.

[35] “UN: All Bakeries Closed, No Flour for Sale in North Gaza.” Fars News Agency, November 8, 2023. https://www.farsnews.ir/en/news/14020817000237/UN-All-Bakeries-Clsed-N-Flr-fr-Sale-in-Nrh-Gaza;

[36] “Half a Million Civilians Caught in Northern Gaza ‘Siege within a Siege’,” Oxfam International, November 3, 2023. https://www.mixcloud.com/Resonance/isotopica-15-october-2023-zanana-sounds-of-war-from-the-gaza-strip/.

[37]  R. Wilson, M. Oliver, and A. Newman. “Gaza’s Limited Water Access, Mapped.” CNN, October 18, 2023. https://www.cnn.com/2023/10/18/middleeast/gaza-water-access-supply-mapped-dg/index.html; F. Marsi, “Gaza’s next Big Threat: Cholera, Infectious Diseases amid Total Blockade.” Al Jazeera, October 21, 2023. https://www.aljazeera.com/news/2023/10/21/gazas-next-big-threat-cholera-infectious-diseases-amid-total-blockade.

[38] “Hostilities in the Gaza Strip and Israel: Flash Update #44.” UNOCHA, November 19, 2023. https://www.unocha.org/publications/report/occupied-palestinian-territory/hostilities-gaza-strip-and-israel-flash-update-44.