Gaza: ailing health-care system puts lives at risk
The steady deterioration of the health-care system has become one of the most worrying issues in Gaza, explains Eileen Daly, who has overseen the ICRC's health activities in the West Bank and Gaza since September 2006.
The system has never been in worse shape, and the reasons are clear: the shortage of electricity, the lack of medical supplies and the deplorable condition of medical equipment. I would say that the system is functioning at less than half its capacity, and thus could probably not cope if confronted with anothe r military operation on the scale of last year's war. Israel, the Palestinian Authority in Ramallah, and the Hamas authorities in Gaza each bear a degree of responsibility. The system is failing because health care is being politicized. Those who suffer the consequences are the health-care providers and, especially, the patients themselves.
Humanitarian organizations can do little more than patch up problems here and there with emergency aid. It is up to the authorities, with support from the international community, to find long-term solutions.
What is the impact of power cuts on the hospitals' ability to function?
Power cuts are one of the main problems faced by hospitals and other providers of essential services in Gaza. Some electricity is purchased from Israel and Egypt, but the rest is produced at a power plant in Gaza that is chronically short of fuel, partly because Israel will not allow sufficient quantities of fuel to be brought in to the territory, but mostly because the authorities in Ramallah and Gaza cannot agree on who should pay.
When the electricity supply is interrupted, emergency back-up generators take over in the hospitals. The fuel required for the generators is not the same as that used in the power plant, but generator fuel is also in very short supply because the Ramallah-based Ministry of Health, which holds the contract for hospital fuel financed by the World Bank, does not send the fuel to Gaza on time. In fact, the situation is the worst it has ever been. These days, hospitals must operate with an average of seven hours of blackout a day.
For this reason, the main hospitals have gone through major crises every month. Shifa Hospital and the European Gaza Hospital had to cancel all elective surgery three times this year and focus on emergency cases only. The European Gaz a Hospital, among others, was forced to close its laundry services several times. Gaza's paediatric hospital once had to transfer its patients to another facility because it could no longer function. The list of fuel-related crises is getting longer by the day.
Blackouts affect all patients connected to machines, including ventilated patients and patients undergoing dialysis treatment. In hospitals still equipped with manual switches, it takes generators a couple of minutes after a blackout occurs to start working. When a circuit board in a dialysis machine fails during treatment, a nurse has to pump the blood manually to prevent coagulation. In 2007, one ventilated patient died because no medical staff were with him when the power failed. The ICRC provided automatic transfer switches to hospitals so that the switchover to generator-produced power could take place immediately. However, because the system cannot cope with so many power fluctuations, the switches often do not work.
Blackouts affect hospital services of all kinds: light bulbs in operating theatres stop working, electronic devices used in surgery suddenly switch off, and dialysis machines, heart monitors, computed tomography scanners, lab analysers, and magnetic resonance imaging devices can suffer breakdowns because of power cuts. Washing machines and autoclaves (used to sterilize equipment) are also vulnerable. Because such equipment keeps breaking down, a constant flow of spare parts must be maintained for repairs.
How does the closure affect the delivery of medical supplies and equipment?
Medical equipment can remain in disrepair for extended periods, because a thicket of bureaucracy has to be overcome to get the necessary spare parts into Gaza.
To bring into the territory materials considered by Israel to be usable for other than medical purposes, it is extremely difficult to obtain approval. Anything electronic, such as laboratory blood analysers, falls into this category. It took the ICRC eight months to bring spare parts for a mammography machine into Gaza.
The transfer of disposable electrodes, which are necessary to monitor the heart rhythm of cardiac patients, has been pending for nearly a year. Because of the shortage, most heart monitors will be unusable in Gaza very soon. Without this equipment, patients'lives are endangered as heart conditions may not be detected in time.
The transfer into Gaza of essential drugs and disposable items has reached an all-time low because of a standstill in cooperation between the Palestinian Authority in Ramallah and the Hamas authorities in Gaza. Certain chemotherapy drugs have been unavailable for some time already. When chemotherapy is discontinued, the chances of success drop dramatically and the patients must start their painful treatment all over again.
More than one of every four disposables that should be available are out of stock. This means that medical staff are forced to re-use (at greater risk of infection) such items as ventilator tubes for artificial ventilation, and colostomy bags, which are used to evacuate intestines after surgery.
What problems are faced by Gazans who need to receive medical treatment outside the territory?
Referrals to hospitals outside Gaza provide an indication of the type of care that is or is not available within the territory. These days, many patients are referred for radiology sc anning. This stems from the fact that, until spare parts or new equipment arrive, Gaza's public CT and MRI scanning equipment will be out of order or only partially functioning. Some patients, including those with cancer and those requiring cardiac catheterization, need to be referred to hospitals outside Gaza owing to the lack of certain drugs and disposables.
One important issue is the high number of pending referral requests for patients needing authorization from Israel to travel outside Gaza. They make up about 30 to 40 per cent of referral requests. This creates havoc in hospitals expecting the patients, most of which are in East Jerusalem and elsewhere in the West Bank. It is not unusual for appointments for surgery to be cancelled at the last minute by patients still awaiting authorization.
Before the closure was imposed, patients requiring specialized care also used to go to Egypt through the Rafah crossing. However, since Rafah cannot be relied upon to be open, there are many problems both for patients and hospitals. When the Rafah crossing suddenly opens for people seeking to enter Egypt from Gaza, several hundred patients go through at the same time. To prevent Egyptian hospitals from being overwhelmed, the Egyptian authorities have had to open a holding centre to smooth the flow of patients. The route through Rafah is in any case far from ideal for emergency cases, since by going through the crossing it takes about eight hours to reach the first hospital.
How do the health-care systems in Gaza and the West Bank compare with each other?
The infant mortality rate – often used as a health indicator – is about 30 per cent higher in Gaza than in the West Bank, where health services have kept improving over recent years. In the West Bank there is a centralized training system for medical staff, and action taken to m eet needs is coordinated with donors providing equipment and supplies.
Gaza, on the other hand, is almost completely isolated. There is chaos at even the most basic level of service delivery. Some specialized training not available in Gaza also cannot be obtained elsewhere because of very severe restrictions on the movement of people into and out of the territory. Essential drugs and disposables are completely lacking, while very sophisticated machines that no one knows how to operate sometimes appear, seemingly out of nowhere, as a result of unsolicited donations. How can there be a health-care strategy in such conditions?
Would increased humanitarian assistance be a solution to the problem?
No, the situation cannot be resolved by providing humanitarian aid alone. The only way to achieve a sustainable solution is to lift the closure and to ensure that health care is not politicized. Until that happens we will maintain our support for hospitals in Gaza, even though there is only so much we can do. We monitor needs on the ground and, together with the Palestine Red Crescent Society, we advise Red Crescent and Red Cross societies, and other organizations that want to help, on what exactly is needed in order to avoid unsolicited donations of drugs or medical equipment that do no real good.