Structural Context and Human Rights: Vaccinating Children in Gaza Against Polio
Nicole B. Alkhouri and Nadia N. Abuelezam
By September 13, 2024, the World Health Organization (WHO) reported that approximately 560,000 children in Gaza had received the first dose of the oral polio vaccine type 2 (cVDPV2) as part of a three-phase initiative from September 1-12 during Israeli-scheduled “humanitarian pauses”.[1] The campaign which targeted approximately 640,000 Gazan children under 10, achieved over 90% coverage, exceeding WHO’s target, with a second round of vaccination completed on November 6, 2024.[2]
This success demonstrates the resilience of Gaza’s families, health workers, and communities, who, despite enduring decades of occupation, structural racism, and violence, managed to prioritize the health of their children to achieve this high vaccination coverage against key infectious diseases.[3] The violence that followed the events of October 7, 2023, has severely disrupted the already fragile healthcare infrastructure, compromising its ability to control infectious disease spread. Rebuilding Gaza’s health system and protecting its children from future outbreaks will require not only local initiatives and resilience but also the concerted involvement of other nations and international organizations independent of Israeli control and influence.
On October 7, 2023, Hamas militants launched an attack on Israel kidnapping more than 200 hostages and killing about 1200 Israelis.[4] Indiscriminate retaliation airstrikes have claimed the lives of more than 15,000 children with 20,000 missing or under the rubble as of October 2024.[5] The military campaign has destroyed over half the buildings in Gaza, leaving up to 1.9 million people displaced.[6] Israel’s targeting of city infrastructure, including sewage and water systems, has led to waste accumulation around the makeshift shelters in Israeli-designated “safe zones” where displaced families now take refuge.[7] Israel has targeted most healthcare facilities leaving only six field hospitals currently fully functional.[8] Gaza’s residents have been struggling to access medical care and basic health services, a situation which has been compounded by limited aid and supplies entering Gaza.[9] With bombings targeting areas near 80% of Gaza’s hospitals, routine vaccinations have been disrupted, adding to the many dangers Gazan children face beyond the immediate threat of Israeli airstrikes.[10] A recent cross-sectional study of 1500 displaced people found that 24.9% and 49.3% of participants had experienced diarrhea and acute respiratory infections, respectively.[11] The dire shortage of clean water, food, shelter, and medication has led to the spread of infectious diseases such as polio, hepatitis, and skin rashes, especially among children.[12]
Although WHO reports over 90% coverage was achieved during the first round of polio vaccinations, there are factors that suggest this estimate may not fully capture the complexities on the ground. Displacement, targeted violence against children and mothers in Gaza, and mistrust toward authorities likely hindered participation. Families prioritizing the physical safety of their children may have avoided travel to vaccination centers which continue to be targeted.[13] The second round of polio vaccination achieved 94% coverage in Gaza overall, however, due to intensifying attacks and mass displacement, in Northern Gaza coverage was only 88%.[14] On October 14, 2024, Israeli airstrikes targeted a school where polio vaccination was set to take place and a major hospital, compromising the safety of children seeking the vaccine and health workers administering it.[15] With approximately 7,000-10,000 children in Northern Gaza—who have had no access to food and clean water since the beginning of October—still unvaccinated, a poliovirus outbreak remains a threat to the lives of these children.[16]
The health of Palestinians has been shaped by a legacy of displacement, marginalization, and systemic inequities that trace back to the Nakba in 1948, which marked the expulsion and displacement of more than 700,000 Palestinians.[17] Since then, Israeli land seizures and illegal settlements have resulted in nearly 280 settlements in the occupied Palestinian territories.[18] This, along with the construction of an over 200-mile-long wall and 700 military checkpoints or obstacles, has segregated and isolated Palestinian communities.[19] These structures have severely restricted access to essential needs such as food, employment, and healthcare, and prevented Palestinians from attaining independence over their healthcare infrastructure. Instead they rely on international organizations to collaborate with Israeli occupying forces to deliver basic needs like vaccinations and medicine. The blockade of Gaza, which began in 2007, has further tightened movement restrictions, making it nearly impossible for patients, many among whom are children, to obtain medications regularly or seek medical treatment outside Gaza without Israeli-issued permits.[20] The health consequences of these structural barriers are compounded by the frequent and abrupt Israeli military campaigns on Gaza over the last 17 years, which have impacted the healthcare system governed by Palestinians, and have directly interrupted vaccination schedules for Palestinian children.[21] For instance, the 2002 siege in the West Bank halted vaccination against measles and tetanus.[22] Most recently in 2021, tensions in the region disrupted COVID-19 vaccination campaigns in Gaza–deepening the already existing gap in vaccination coverage between Palestinians and their Israeli counterparts.[23]
Despite the limited resources allowed into Gaza and the structural factors that frequently interrupted access to and provision of health services, local Palestinian efforts, supported by international organizations and nonprofits, managed to maintain effective control over infectious diseases and vaccine distribution. Prior to October 7, vaccination coverage for major diseases was mostly above 90%, highlighting the collective emphasis on protecting children’s health through vaccination.[24] As an illustrative example, in 2015, infectious diseases accounted for only 2.4% of all reported deaths compared to chronic diseases like cardiovascular disease and cancer which comprised 27.5% and 13.8% of deaths, respectively.[25] Since October 7, the United Nations reported 40,000 cases of hepatitis A compared to 85 cases during the same period in previous years underscoring both the extenuating circumstances leading to these infections and the importance of vaccination during this time.[26] While the pre-October 7 health infrastructure in Gaza may have been sufficient for meeting some of the population’s immediate needs, it was not well suited for long-term health challenges such as chronic diseases or future conflicts that the population may endure.
The well-being and survival of children in Gaza requires far more than a vaccine. Ending the current outbreaks and preventing future ones necessitates reliable access to food, water, shelter, and vaccinations, all of which are basic human rights that are being undermined by historical and systemic injustices controlled by Israel. While emergency vaccination campaigns are not unique to Gaza, the current campaign must overcome the lack of aid entering Gaza, the overcrowding people are facing, ongoing violence, and mass displacement. Addressing gaps in vaccination requires long-term and concrete steps to dismantle barriers to care, tackle broader inequities, ensure Palestinian sovereignty, and uphold Palestinians’ fundamental right to health. This should start with an immediate ceasefire, unrestricted entry of humanitarian aid, and a global commitment to addressing the root causes of systemic racism and inequality that drive Palestinian health disparities.
Nicole B. Alkhouri, MS, is a research associate at Michigan State University, United States.
Nadia N. Abuelezam, ScD, is an associate professor and epidemiologist at Michigan State University, United States.
Please address correspondence to Nicole B. Alkhouri. Email: alkhour6@msu.edu.
Copyright © 2024 Alkhouri and Abuelezam. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction.
References
[1] World Health Organization, “Around 560 000 children vaccinated in first round of polio campaign in Gaza,” (n.d.), Available at https://www.who.int/news/item/13-09-2024-around-560-000-children-vaccinated-in-first-round-of-polio-campaign-in-gaza.
[2] World Health Organization (see note 1); “Second round of polio campaign in Gaza completed amid ongoing conflict and attacks: UNICEF and WHO,” (n.d.), Available at https://www.who.int/news/item/06-11-2024-second-round-of-polio-campaign-in-gaza-completed-amid-ongoing-conflict-and-attacks–unicef-and-who.
[3] “WHO Immunization Data portal – Eastern Mediterranean Region,” Immunization Data, (n.d.), Available at https://immunizationdata.who.int/dashboard/regions/eastern-mediterranean-region.
[4] C. Vinograd, and I. Kershner, “Israel’s Attackers Took About 240 Hostages. Here’s What to Know About Them.,” The New York Times (November 20, 2023).
[5] “Half Billion Children Trapped in Conflict Face Grave Rights Offenses, Third Committee Told, as Delegate Stresses Minors ‘Innocent on Both Sides’ | Meetings Coverage and Press Releases,” (n.d.), Available at https://press.un.org/en/2024/gashc4410.doc.htm.
[6] “UNRWA Situation Report #118 on the situation in the Gaza Strip and the West Bank, including East Jerusalem,” UNRWA, (n.d.), Available at https://www.unrwa.org/resources/reports/unrwa-situation-report-118-situation-gaza-strip-and-west-bank-including-east-Jerusalem.
[7] “‘We have nothing.’ As Israel attacks Rafah, Palestinians are living in tents and searching for food,” AP News, (2024); “United Nations Office for the Coordination of Humanitarian Affairs – occupied Palestinian territory | Reported impact snapshot | Gaza Strip (19 June 2024),” United Nations Office for the Coordination of Humanitarian Affairs – occupied Palestinian territory, (2024), Available at http://www.ochaopt.org/content/reported-impact-snapshot-gaza-strip-19-june-2024.
[8] “oPt Emergency Situation Update,” (World Health Organization, 2024), Available at https://www.emro.who.int/opt/information-resources/emergency-situation-reports.html.
[9] J. Frankel, J. Jeffery, and S. Magdy, “Why is only limited aid getting to Palestinians inside Gaza?,” AP News, (2024).
[10] D. Kunichoff, D. Mills, Y. Asi, et al., “Are hospitals collateral damage? Assessing geospatial proximity of 2000 lb bomb detonations to hospital facilities in the Gaza Strip from October 7 to November 17, 2023,” PLOS Global Public Health 4/10 (2024), p. e0003178.
[11] K. Zinszer, and S. Abuzerr, “Water, Sanitation, and Hygiene insecurity and infectious disease outbreaks among internally displaced populations in Gaza: implications of conflict-driven displacement on public health,” Journal of Water, Sanitation and Hygiene for Development (2024), p. washdev2024361.
[12] J. E. Kearney, N. Thiel, A. El-Taher, et al, “Conflicts in Gaza and around the world create a perfect storm for infectious disease outbreaks,” PLOS Global Public Health 4/2 (2024), p. e0002927.
[13] “Israel obstructs polio vaccination campaign in Gaza with its military attacks, detention of UN convoy,” Euro-Med Human Rights Monitor, (n.d.), Available at https://euromedmonitor.org/en/article/6463/Israel-obstructs-polio-vaccination-campaign-in-Gaza-with-its-military-attacks,-detention-of-UN-convoy.
[14] World Health Organization (see note 2).
[15] “United Nations Office for the Coordination of Humanitarian Affairs – occupied Palestinian territory | Reported impact snapshot | Gaza Strip (19 June 2024),” United Nations, (2024), Available at http://www.ochaopt.org/content/reported-impact-snapshot-gaza-strip-19-june-2024.
[16] World Health Organization (see note 2).
[17] A. Qabaha, and B. Hamamra, “The Nakba Continues: The Palestinian Crisis from the Past to the Present,” Janus Unbound: Journal of Critical Studies 1/1 (2021), pp. 30–42.
[18] C. Heaney, “Human Rights Council Hears that 700,000 Israeli Settlers are Living Illegally in the Occupied West Bank – Meeting Summary (Excerpts),” Question of Palestine, (n.d.).
[19] IMEU, “Explainer: Israel’s West Bank Wall | IMEU,” (n.d.), Available at https://imeu.org/article/israels-west-bank-wall.; “Over 700 road obstacles control Palestinian movement within the West Bank,” United Nations Office for the Coordination of Humanitarian Affairs – occupied Palestinian territory, (2018), Available at http://www.ochaopt.org/content/over-700-road-obstacles-control-palestinian-movement-within-west-bank.
[20] “Patients in the Gaza Strip unable to obtain Israeli-issued permits to access the healthcare,” World Health Organization – Regional Office for the Eastern Mediterranean, (n.d.), Available at http://www.emro.who.int/opt/news/patients-in-the-gaza-strip-unable-to-obtain-israeli-issued-permits-to-access-the-healthcare.html.
[21] C. Mason, “Gaza’s health care system crippled before — and after,” CMAJ : Canadian Medical Association Journal 180/6 (2009), p. 608.
[22] R. Khatib, and S. Halileh, “The impact of Israeli incursion, siege and closure on the immunization program in the West Bank – Israel | ReliefWeb,” (2002); R. Giacaman, “A population at risk of risks: no one is in a healthy state in Palestine,” Birzeit University, Institute of Community and Public Health, (2002), available at http://hdl.handle.net/20.500.11889/826.
[23] N. Howard, and E. Schneider, “COVID-19 Vaccination in Palestine/Israel: Citizenship, Capitalism, and the Logic of Elimination,” Health and Human Rights 24/2 (2022), p. 265; E. Cunningham, “Israel’s military assault on Gaza threatens to worsen the pandemic in the enclave,” Washington Post (May 13, 2021).
[24] World Health Organization (see note 3).
[25] “Country cooperation strategy for WHO and the Occupied Palestinian Territory 2017–2020,” (World Health Organization, n.d.).
[26] “Gaza: ‘Frightening increase’ in Hepatitis A cases | UN News,” (2024), Available at https://news.un.org/en/story/2024/08/1152791.