Each individual's health is influenced by a complex interplay of biological and social factors that shape its personal growth. When political stability is highly compromised within a society, as in the case of a war, the resulting disruption negatively affects the relation between health and individual well-being. This relationship is evident in Gaza, where Palestinians have adopted a subjectively natural yet objectively unnatural recognition of the difficult social conditions they are living in, as new generations were born amid ongoing violence and conflict. In this context the right to health, an inclusive right that extends beyond timely medical care to encompass determinants of health such as access to clean water and adequate nutrition, has been progressively eroded. Since Israel's blockade of Gaza in 2007, followed by four Israeli military operations in 2008/09, 2012, 2014, and 2021, the population of Gaza has faced a deterioration of living conditions with repeated exposure to conflict, the impossibility of leaving Gaza for many, and the systematic destruction of critical infrastructure which destabilised the determinants of health.
However, the ongoing conflict, which began on October 7, 2023, represents a point of no return compared to the previous situation as the Israeli military operation has affected all segments of Palestinian society.
As reported in the OCHA Bulletin of November 2024, one year after the war began, the death toll has reached 40,717, with 13,319 of those being children, representing 32.5% of the total. At the beginning of the war, Gaza had 36 hospitals, but only 17 now remain partially operational, struggling under immense pressure to meet the overwhelming demand for medical care (OCHA, 2024). In this context, deaths occur not only from direct violence but also from indirect violence, including the spread of infectious diseases, which often proliferate in deteriorating healthcare conditions. This is particularly devastating in a situation where nearly 2 million people have been displaced and are living in overcrowded makeshift camps with a density of almost 40,000 people per square kilometer (IPC, 2024). The fact that residents in Gaza now have access to only 4.74 liters of water per person per day further exposes them to serious health risks (OXFAM, 2024).Without significant and sustained improvements in aid access, civilian protection, and humanitarian security, Gaza faces the imminent threat of catastrophic famine. Such an outcome could result in an even more devastating loss of life for Palestinians, potentially leading to a full-scale humanitarian disaster.
The Deterioration of Gaza's Healthcare Infrastructure: A Historical Analysis of a System on the Verge of Collapse
The Gaza Strip is one of the world's most densely inhabited areas with almost 2.3 million people living in a 365-square-kilometre territory. During the last years, its healthcare system has witnessed a dramatic crisis exacerbated by episodes of political violence such as the Israeli blockade's imposition in 2007, Palestinian political intra division and five major Israeli military operations in 2008, 2012, 2014, 2021 and 2023. Over time, in this region of the world, the right to health has increasingly become antithetical to the idea of a right that guarantees a standard of living adequate for human well-being as written in Universal Declaration of Human Rights. In this context, a significant number of hospitals and primary healthcare centers have been destroyed or damaged, with 34 hospitals and 104 PHC centers affected between 2008 and 2021 by Israeli military operations (WHO 2009; MAP 2014; WHO 2014; ReliefWeb 2021). As of 2023, the healthcare system was already on the verge of collapse, with just 36 hospitals in operation and a total of 3,412 hospital beds available for a population exceeding 2 million people (Soni, 2024). However, if we consider the situation of Palestinians in Gaza as traumatic in the years ex ante October 7, 2023, the events following can be seen as a form of structural violence, aimed at undermining Palestinian human dignity. Since the Israel-Hamas war began in October 2023, 19 hospitals became non-functional reducing the number of operational hospitals to just 17 (OCHA, 2024). Additionally, the number of available beds in Gaza's operating hospitals and field hospitals has dropped to fewer than 1,500, which is insufficient to accommodate the needs of over two million people facing war ( Euro-Med, 2024). Cities with similar population sizes, such as Paris, with approximately 2.1 million residents, has around 10,000 hospital beds available (INSEE, 2024). A disparity made even more concerning by the fact that 1,047 health workers died (OCHA, 2024). The destruction or dismantling of key societal segments in Gaza has undermined the very fabric of society that support everyday life and human dignity. The systemic reduction of these societal segments such as healthcare, education, and humanitarian aid institutions forces Palestinians to cope with not just physical devastation, but also to endure the long-term psychological trauma of living in a society that has lost its foundational supports. An emblematic example of the dismantling of key societal segments can be seen in the new legislation passed by the Israeli parliament in late October 2024, which barred UNRWA from operating within Israeli-controlled territories and prohibited coordination between Israeli officials and UNRWA staff. UNRWA provides health services to over 1.2 million Palestinian refugees through 22 centers, and this decision may severely disrupt its ability to procure supplies, ensure staff mobility, and coordinate access to high-risk areas. This will further exacerbate the humanitarian crisis in Gaza, threatening the lives of refugees who depend on UNRWA for essential services.
Malnutrition and Health: The result of Food Insecurity, Scarce Water, and Disease
Modern societies rely heavily on interconnected systems such as transportation networks, communication grids, water supply and energy systems. We consider these systems "invisible" in the sense that they are taken for granted until they fail. War poses a significant threat to these interdependent systems, as failures in one part of these complex networks can trigger cascading effects, leading to widespread and catastrophic consequences. This dynamic is reflected in the conflict in Gaza where nearly 60% of buildings and 68% of roads are destroyed, resulting in the collapse of food, health, and water systems. As a result, nearly 2 million people are facing severe food insecurity, including an estimated 60,000 children aged 6 to 59 months projected to suffer from acute malnutrition between September 2024 and August 2025 (IPC, 2024). The destruction of health infrastructure and lack of access to safe water have further exacerbated disease outbreaks with over 25% of Gaza's population affected by preventable illnesses (OXFAM, 2024). On a global scale, every day, nearly 4,000 people die from diseases caused by inadequate access to safe drinking water, sanitation, and hygiene (WASH) with over 1,000 of these deaths occurring among children under the age of five (UNICEF, 2023).Deprivation in WASH traps individuals and communities in conditions of vulnerability, inequality, and deprivation reducing them to a state of survival. As written by Amartya Sen in Development as Freedom, access to clean water and sanitation is a basic capability vital for health, nutrition, and dignity, enabling individuals to live lives they value. Its limitation represents a form of " unfreedom," trapping marginalized communities in cycles of poverty and vulnerability (Sen, 1999). The water situation in Gaza is a critical example: 97% of the Gaza aquifer, the primary source of drinking water, is contaminated and unsafe for consumption due to seawater intrusion and sewage contamination (EcoPeace Middle East, 2024).Before the 2023 Israel-Hamas war, Gaza relied on groundwater (81%), desalination (6%), and water purchased from Israel's Mekorot company (12%). Palestinians had 82.7 litres per person per day which was below the WHO recommended daily quantity of 100 litres per person. However, after the war, 88% of the wells and 70% of wastewater pumps were severely impacted and water production fell by 84%. Most alarmingly, people in Gaza now have access to just 4.74 litres of water per person per day for all purposes, including drinking, cooking, and washing, representing a dramatic 94% reduction in water availability (OXFAM, 2024). In comparison, the average European uses 144 litres of water per person per day (Ferguson, 2024). If the conflict continues, with escalating destruction of critical infrastructure and the rapid spread of communicable diseases, Gaza could face a catastrophic famine. This scenario occurs when an area has at least 20% of households facing an extreme lack of food, 30% of children suffering from acute malnutrition, and a death rate of two adults or four children per 10,000 people each day. The entire Gaza Strip is at risk of this possible event (IPC, 2024).
Disease Outbreaks and Public Health Risks: The Surge in Communicable and Non-Communicable Diseases in Gaza
When discussing infectious diseases, we refer to illnesses caused by infectious agents like bacteria, viruses, parasites, fungi, and their toxic byproducts. Many are communicable, meaning they can spread between people or animals. Transmission can occur directly through blood or bodily fluids, indirectly via contaminated food, water, air, or surfaces, or through vectors like mosquitoes. Examples include measles, malaria, chlamydia, and polio (Australian Institute of Health and Welfare, 2024). The history of armed conflicts has revealed that communicable diseases can cause death rates equal or beyond those from direct violence (Goniewicz et al. 2021). The crisis in Gaza is no exception and has created a perfect storm for communicable disease due to the destruction of water and sanitation infrastructure with internally displaced people living in tents or shelters with limited access to safe drinking water and streets full of untreated wastewater and sewage (OCHA,2024). In this context, since October 2023, 40,000 cases of hepatitis A have been recorded in Gaza, a significant increase from just 85 cases before the conflict. In addition, WHO has reported nearly a million cases of acute respiratory infections, over half a million of acute diarrhea, and more than 100,000 cases of jaundice (WHO, 2024). Polio remains a major concern in Gaza, with the cVDPV2 variant detected in sewage samples in June and the first confirmed case in a 10-month-old baby reported in August. However, a vaccination campaign successfully reached 94% of the target population, although 10,000 children in hard-to-reach areas remain unvaccinated and at risk (Sah, 2024). On the other hand, when addressing Non-Communicable Diseases (NCDs) we refer to chronic conditions that are not caused by infectious agents but instead result from a combination of genetic, environmental, and lifestyle factors. These include diabetes, cardiovascular diseases, cancer, and chronic respiratory diseases (WHO, 2023). In Gaza, the conflict has severely worsened the situation for NCD patients, with essential medications like insulin and cancer treatments in critically short supply, and 350,000 people with chronic illnesses having little or no access to necessary medical procedures such as dialysis (Ashour et al. 2024). As of December 3, 2024, an estimated 14,000 patients in Gaza require urgent medical evacuation, but only 352 have been successfully evacuated since the Rafah Crossing closure on May 7, 2024 (OCHA, 2024). This low percentage highlights significant challenges within the referral system, including delays in obtaining permits from Israeli authorities leaving critical patients without timely access to life-saving care.
The impact of the war on Child and Maternal Mental Health: A Crisis of Trauma and Dramatic Loss
Involving children in armed conflict is not only a profoundly inhumane act, but a conscious effort aimed at transforming them into mere statistics of violence, reducing their humanity to a tragic arithmetic of casualties. This is a phenomenon of de-humanization in paradox to the idea that a child, for the full and harmonious development of his or her personality, should grow up in an atmosphere of happiness, love and understanding as written in the UN Convention on the Rights of the Child. In Gaza, nearly all of the 1.2 million children require mental health and psychosocial support (UNICEF, 2023). Even prior to the Israel-Hamas war, Gaza faced a mental health crisis among children. A 2018 survey by Save the Children found that 95% of Palestinian children in Gaza experienced mental health issues like depression, hyperactivity, and aggression (Save the Children Canada, 2018). By 2022, the situation had worsened, with an alarming increase in children expressing fear, anxiety, sadness, and grief (Save the Children, 2022).
However, the Israel-Hamas war dramatically worsened this situation. One year after the war's escalation, the death toll for children in Gaza has reached 13,319, with an average of 70 children injured daily since the conflict began (OCHA, 2024; UNICEF, 2024).
This devastating loss and the ongoing injuries have caused immense psychological harm. The trauma of losing family members and living in constant fear has significantly damaged children's physical, cognitive, and emotional development, leaving many without the support they need for recovery.
However, the impact of armed conflict on children cannot be considered in isolation from women, their primary caregivers. Women often face significant physical and psychosocial challenges during war, which directly affect their ability to care for children. This is particularly critical for pregnant women in armed conflicts, who endure severe psychological trauma and face dangerous conditions, such as home deliveries, induced deliveries, or births in precarious circumstances, including at military checkpoints.
As reported in the WHO Bulletin of November 2024, around 50,000 women are currently pregnant, with approximately 5,500 expected to give birth in the coming month (WHO, 2024). Each day, around 183 women give birth in Gaza, but the availability of midwives, doctors, and postpartum care is extremely limited. Many women have been forced to deliver without medical assistance, with some even undergoing C-sections without anesthesia. In this context, the lack of proper care and the constant fear for their own safety and that of their newborns has significantly worsened their mental and physical health, leading to higher risks of complications such as premature births and stillbirths, as well as a rise in postpartum depression (ICR, 2024).
Ensuring Protection: The Role of International Law in Safeguarding the Right to Health in Conflict Zones
The right to health can be understood as an a-temporal and inclusive right inherent in the life of every individual. It persists across time as it embodies an intrinsic notion of a-temporality, and it extends not only to timely and appropriate healthcare but also to the underlying determinants of health. It serves as a means of liberating individuals from conditions of insecurity, as it ensures the opportunity to lead a healthy life with adequate standard of living necessary for well-being. Article 25 of the Universal Declaration of Human Rights (UDHR) and Article 12 of the International Covenant on Economic, Social, and Cultural Rights (ICESCR) form the cornerstone of this principle. Article 25 emphasizes the right to access not only medical care but also other basic needs like food, housing, and social services (United Nations, 1948). Similarly, Article 12 of the ICESCR ensures the right to the highest attainable standard of physical and mental health, encompassing the provision of essential health services and factors like sanitation, housing, and nutrition (United Nations, 1966).
In addition, the Fourth Geneva Convention mandates the occupying power to "ensure and maintain" the health system and prevent the spread of disease. Consequently,Israel, as an occupying power in Gaza, has clear obligations to ensure the provision of health services for Gazans. Furthermore, the Geneva Conventions protect health workers and facilities, prohibiting attacks on medical infrastructure and personnel. These protections are codified in Article 18 of the Fourth Geneva Convention and Protocol I, Article 12 of the Additional Protocols (ICRC, 1949; 1977). In this context, intentional attacks on healthcare can constitute war crimes under the Rome Statute of the International Criminal Court (ICC, 1998) despite IHL allows for exceptions when healthcare facilities are used for military purposes. However, decisions involving these exceptions must follow the principle of proportionality, which requires balancing military advantage against the potential harm to civilians. While International Humanitarian Law (IHL) provides some guidelines, the current framework offers limited clarity on how healthcare infrastructure should be adequately protected during armed conflicts. This ambiguity has led to calls for amending the Geneva Conventions to unequivocally prohibit attacks on healthcare facilities, regardless of military considerations.
Conclusion
After 12 months of conflict in Gaza, the situation has reached an unprecedented level of devastation, with widespread destruction, immense humanitarian suffering, and severe economic collapse. As reported by the Integrated Food Security Phase Classification (IPC), the Gaza Strip faces the imminent threat of catastrophic famine. To address this situation, immediate actions are required. First, there must be an immediate and lasting humanitarian ceasefire among all parties to the conflict, ensuring the protection of civilians and the unconditional release of all civilian hostages by Hamas and other armed groups. Urgent medical cases in Gaza must be allowed safe access to critical healthcare, with injured or sick children evacuated alongside family members. Preventing and managing acute malnutrition is also essential, including scaling up feeding programs and improving infant and child nutrition practices such as breastfeeding support. Furthermore, humanitarian access must be granted to deliver lifesaving multi-sectoral assistance, addressing acute food insecurity and malnutrition with sufficient and high-quality aid. This aid should extend beyond household food assistance to include the restoration of health services, WASH, and non-food items. Long-term recovery will also require rehabilitating critical infrastructure, restoring market systems, local food production and essential services like electricity and telecommunications. Ultimately, the ongoing conflict has caused cumulative trauma, where repeated exposure to destruction has eroded the collective sense of security. As a result, it will be crucial to implement psychological support programs, particularly for the most vulnerable populations such as children, women and elderly people.
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