During the 22 days of the Israeli military operation, nowhere in Gaza was safe for civilians. Hospitals were overwhelmed with casualties, including small children, women and elderly people. Medical personnel showed incredible courage and determination, working around the clock to save lives in extremely difficult circumstances. Meanwhile, daily rocket attacks launched from Gaza put thousands of residents at risk in southern Israel. Medical workers in Israel provided care for the traumatized population and treated and evacuated casualties.

Many people in Gaza lost a child, a parent, another relative or a friend. Israel's military operation left thousands of homes partly or totally destroyed. Whole neighbourhoods were turned into rubble. Schools, kindergartens, hospitals and fire and ambulance stations were damaged by shelling.

This small coastal strip is cut off from the outside world. Even before the latest hostilities, drastic restrictions on the movement of people and goods imposed by the Israeli authorities, particularly since October 2007, had led to worsening poverty, rising unemployment and deteriorating public services such as health care, water and sanitation. Insufficient cooperation between the Palestinian Authority in Ramallah and the Hamas administration in Gaza had also hit the provision of essential services. As a result, the people of Gaza were already experiencing a major crisis affecting all aspects of daily life when hostilities intensified in late December.

Six months later, restrictions on imports are making it impossible for Gazans to rebuild their lives. The quantities of goods now entering Gaza fall well short of what is required to meet the population's needs. In May 2009, only 2,662 truckloads of goods entered Gaza from Israel, a decrease of almost 80 per cent compared to the 11,392 truckloads allowed in during April 2007, before Hamas took over the territory.

Gaza neighbourhoods particularly hard hit by the Israeli strikes will continue to look like the epicentre of a massive earthquake unless vast quantities of cement, steel and other building materials are allowed into the territory for reconstruction. Until that happens, thousands of families who lost everything will be forced to live in cramped conditions with relatives. Others will continue to live in tents, as they have nowhere else to go.

Emergency repairs carried out after the military operation have made it possible to restore water and sanitation services, but only to the already unsatisfactory level prevailing before December 2008. The infrastructure is overloaded and remains subject to breakdown. Although chlorine is used to disinfect the water, the risk of sewage and other waste matter seeping into the water supply network represents a major threat to public health.

Every day, 69 million litres of partially treated or completely untreated sewage – the equivalent of 28 Olympic-size swimming pools – are pumped directly into the Mediterranean because they cannot be treated.

Thousands of homes only have access to running water on certain days. Because the water supply network cannot be properly maintained, it is leaking, making it harder to maintain sufficient water pressure. Even when water is available in the pipes, many homes do not have sufficient power to pump it into rooftop storage tanks.

The taps of tens of thousands of people run dry when Gaza's municipal water wells break down, which frequently happens because of insufficient supplies of new water pipes, electrical spare parts, pumps and transformers.

The ICRC has occasionally found ways of repairing infrastructure without relying on imports. For example, it used recycled materials (including used water pipes and concrete segments of the old Rafah border wall destroyed in January 2008) to upgrade a wastewater treatment plant serving 175,000 people in Rafah.

However, on its own this is insufficient. Other repairs and reconstruction projects are urgently needed to prevent the further deterioration of the water supply system, carry out essential maintenance and stem the steady decline of the water and sanitation system throughout the Gaza Strip. The fact that water and sanitation services could collapse at any moment raises the spectre of a major public health crisis.

The only way to address this crisis is to lift import restrictions on spare parts, water pipes and building materials such as cement and steel so that homes can be rebuilt and vital infrastructure maintained and upgraded.

Gaza's health-care system cannot provide the treatment that many patients suffering from serious illness require. Tragically, a number of them are not allowed to leave the Strip in time to seek health care elsewhere. Health issues in Gaza are often politicized and patients find themselves caught up in a bureaucratic maze. The procedures for requesting permission to leave the territory are complicated and involve both the Palestinian and Israeli authorities. Seriously ill patients sometimes have to wait for months before the relevant authorities allow them to leave the Gaza Strip.

Even when patients do obtain the necessary permits to leave, the transfer through Erez crossing into Israel can be arduous. Patients on life-support machines have to be removed from ambulances and placed on stretchers, then carried 60-80 metres through the crossing to ambulances waiting on the other side. Patients who can walk unassisted may face extensive questioning before they are allowed through the crossing for medical treatment – or, as sometimes happens, before they are refused entry into Israel and turned back.

The shortage of basic medicines is a constant problem for Gaza hospitals and health clinics. They depend on a timely and reliable supply of medicines from the Palestinian Authority's Ministry of Health in the West Bank, but the supply chain often breaks down. Cooperation between the health authorities in the West Bank and Gaza is difficult. Complex and lengthy Israeli import procedures also hamper the reliable supply of even the most basic items such as painkillers and X-ray film developers. As a result, some patients, including people suffering from cancer or kidney failure, do not always get the essential drugs they need.

An estimated 100-150 people who lost limbs in the recent military operation are waiting to be fitted with artificial limbs. The ICRC-supported Artificial Limb and Polio Centre (ALPC) is the only physical rehabilitation centre in Gaza that can provide them with adequate rehabilitation and professional customized appliances. Being the only limb fitting centre in the Gaza Strip, the ALPC has to respond to the entire demand for artificial limbs. Yet importing prosthetic materials and components is still a difficult and lengthy process.

Gaza's hospitals are run down. Much of the equipment is unreliable and in need of repair. Complicated procedures for obtaining approval to import spare parts make it difficult and time consuming to bring in and maintain hospital equipment, such as CT scanners, and spare parts – even for hospital washing machines. The ICRC has had to wait as long as five months to import medical equipment for operating theatres, such as orthopaedic external fixators.

Daily power cuts and power fluctuations continue to damage medical equipment. Most hospitals have to rely on backup generators for several hours a day, but it is never certain that enough fuel will be available to run them.

Seriously ill patients should be given prompt and safe passage out of the Gaza Strip in order to access the specialized medical care they cannot get inside the territory. Essential medical items such as drugs, disposables and spare parts must be allowed into the Gaza Strip without delay and in sufficient quantities to ensure essential health services for the population.

One of the gravest consequences of the closure is soaring unemployment, which reached 44 per cent in April 2009, according to the Gaza Chamber of Commerce. Restrictions on imports and exports of goods imposed since June 2007 have shut down 96% of industrial operations in Gaza, with the loss of about 70,000 jobs. This has also had a severe impact on the capacity to export products to Israel and the West Bank, which has become almost impossible.

The tunnels under the Egypt-Gaza border do not present an alternative route to economic development and are not ensuring a sufficient supply of affordable goods for the population.

The collapse of the Gaza economy has led to a dramatic increase in poverty. An ICRC household survey conducted in May 2008 showed that, even then, over 70 per cent of Gazans were living in poverty, with monthly incomes of less than 250 US dollars for a family of 7 to 9 members (1 dollar per household member per day, excluding the value of humanitarian assistance which they may receive). Up to 40 per cent of Gaza families are very poor; with a monthly income of under 120 dollars (0.5 dollar per household member per day). On average, each person who does work – whether as a paid employee or running their own business – has to support their immediate family of 6-7 people and a few members of their extended family.

This increase in poverty has taken a heavy toll on the population's diet. Many families have been forced to cut household expenses to survival levels. Generally, people are getting the calories they need, but only a few can afford a healthy and balanced diet. Poor families often substitute cheaper alternatives such as cereals, sugar and oil for fruits, vegetables, meat and fish. For tens of thousands of children, this has resulted in deficiencies in iron, vitamin A and vitamin D. The likely consequences include stunted growth of bones and teeth, difficulty in fighting off infections, fatigue and a reduced capacity to learn.

Most of the very poor have exhausted their coping mechanisms. Many have no savings left. They have sold private belongings such as jewellery and furniture and started to sell productive assets including farm animals, land, fishing boats or cars used as taxis. They are unable to reduce spending on food any further. The declining living standards will affect the health and well-being of the population in the long term. Those worst affected are likely to be children, who make up more than half of Gaza's population.

Gaza's alarming poverty is directly linked to the tight closure imposed on the territory. Local industry and other businesses have to be allowed to rebuild, to import essential inputs and to export their products. But even that would take time. The crisis has become so severe and entrenched that even if all crossings were to open tomorrow it would take years for the economy to recover.

The closure has also badly hit farming families, which make up over a quarter of Gaza's population. Exports of strawberries, cherry tomatoes and cut flowers used to be an important source of income. They have come to a virtual standstill. Many farmers have had their income halved as they find it difficult to sell their entire harvest inside Gaza. Even if they succeed, the price they obtain is only a fraction of what they would normally earn from exports to Israel or Europe.

During the latest military operation, the Israeli army uprooted thousands of citrus, olive and palm groves, including those far inside the Gaza Strip. The army also destroyed irrigation systems, wells and greenhouses.

Many farmers are effectively denied access to parts of their land because of the Israeli-imposed "no-go" zone on the Gaza side of the border fence with Israel. At least 30 per cent of the arable land in Gaza lies within this buffer zone, which can extend up to one kilometre from the fence. A farmer never knows for sure if it is safe to work his land or to harvest within the zone. Farmers risk being shot at when tending to their land and incursions by the army often leave fields and parts of the harvest destroyed.

Getting agricultural production up and running again is difficult not only because of the destruction that has occurred, but also because Israel does not allow the importation of suitable fertilizers and because many types of seedlings are difficult or even impossible to find in Gaza.

Fishing has also been hard hit by the Israeli-imposed restrictions on movement. Last January, the area at sea within which Israel allows fishing was cut from six to three nautical miles from Gaza's coastline, reducing catches and therefore the availability of this protein-rich food. Bigger fish and sardines, which constituted some 70 per cent of the catch before 2007, are found mainly outside the three-nautical-mile zone.

Urgent steps must be taken to allow farmers to resume growing their crops in safety. Fertilizers, spare parts for machinery, plastic sheeting for greenhouses and fodder must be allowed into the Gaza Strip in quantities that will ensure that they are sold at prices farmers can afford. At the same time, farmers must be permitted to resume their exports of produce in order to earn a proper living. Recent restrictions on fishing should be rescinded.

People in Gaza are trapped. Because Israel has shut the crossing points, Gazans have scant opportunity for contact with relatives abroad or for further education or professional training. The restrictions on leaving and entering the Gaza Strip also apply to Palestinian staff of international organizations such as the ICRC. To make matters worse, it is seldom possible to use the Rafah border point with Egypt.

The emotional fallout from the closure is particularly apparent among families with relatives imprisoned in Israel. In June 2007, Israel stopped ICRC-supported visits by about 900 Gaza families to their detained relatives. As a result, many children have lost their one remaining link with a detained parent or sibling. These families must be allowed to resume visits to their relatives in Israeli detention.

Often, university students with grants to study abroad are not allowed to leave Gaza. Those who cannot leave are left with limited options for further education within the coastal enclave. University professors, teachers and health professionals are often prevented from participating in training courses and seminars abroad that would help them upgrade their skills and expertise.

Over the last two years, the 1.5 million Palestinians living in the Gaza Strip have been caught up in an unending cycle of deprivation and despair as a result of the conflict, and particularly as a direct consequence of the closure of the crossing points.

The ICRC has repeatedly pointed out that Israel’s right to address its legitimate security concerns must be balanced against the right of the population in Gaza to lead a normal and dignified life. Under international humanitarian law, Israel has the obligation to ensure that the population's basic needs in terms of food, shelter, water and medical supplies are met.

The ICRC once again appeals for a lifting of restrictions on the movement of people and goods as the first and most urgent measure to end Gaza's isolation and to allow its people to rebuild their lives.

The almost 4.5 billion dollars that donor countries pledged for reconstruction at an international summit in Egypt in March 2009 will be of little use if building materials and other essential items cannot be imported into the Gaza Strip.

In any case, reconstruction alone does not offer a sustainable means of getting Gaza back on its feet. To go back to the situation prior to the latest military operation would be unacceptable, as that would only perpetuate Gaza’s plight.

A lasting solution requires fundamental changes in Israeli policy, such as allowing imports and exports to and from Gaza, increasing the flow of goods and people up to the level of May 2007, allowing farmers to access their land in the de-facto buffer zone and restoring fishermen's access to deeper waters.

Humanitarian action can be no substitute for the credible political steps that are needed to bring about these changes. Only an honest and courageous political process involving all States, political authorities and organized armed groups concerned can address the plight of Gaza and restore a dignified life to its people.

The alternative is a further descent into misery with every passing day.

ICRC activities in Gaza

The ICRC has had a permanent presence in the Gaza Strip since 1968. There are currently 109 ICRC staff working there, including 19 expatriates.

ICRC staff remained in Gaza throughout the Israeli military operation launched on 27 December 2008. In cooperation with the Palestine Red Crescent Society (PRCS), they evacuated hundreds of people – some of whom were severely wounded in the fighting. In addition, they provided hospitals with vital medicines and supplies, and ICRC war surgeons helped perform operations in Gaza's Shifa Hospital.
Working with local authorities, the ICRC also carried out emergency repairs on the power and water supply lines.

In the aftermath of the military operation, the ICRC and the PRCS distributed relief items such as plastic sheeting, cooking sets, mattresses, blankets and hygiene kits to more than 72,000 Gazans whose houses had been partially or totally destroyed. ICRC delegates also gathered information on whether Israel and Palestinian groups conducted hostilities in accordance with international humanitarian law. The ICRC's findings are being discussed bilaterally with the authorities concerned.

At present, the ICRC is supplying eight hospitals with medicines and other medical items, equipment and spare parts, and is helping to maintain and repair ambulances. In addition, the ICRC is fitting amputees with artificial limbs and providing them with physiotherapy. It is helping to upgrade water and sanitation services and to maintain the water network. The organization is providing support for farmers and others in need through various programmes involving land rehabilitation, compost production and "cash for work."
The ICRC continues to visit detainees in the Gaza Strip and to promote knowledge of and respect for international humanitarian law among the authorities and weapon bearers.