Salam Khashan’s shifts at the Nasser Medical Complex in Gaza can exceed 24 hours.
“When I am in the ER, and I call for a bed because I have, for example, a patient with hypoglycemia who needs to be admitted, they usually answer that we don't have a bed,” the doctor said. In that scenario, the patient may have to wait in the emergency room for hours as Khashan, an OB-GYN, calls other departments to search for an empty bed.
“Sometimes we have patients whose diagnoses and treatment plan we know, but we cannot treat them in Gaza because we don't have the medications,” she said. “We have a [medication] shortage by about 50 percent.”
What Khashan described may sound newly familiar to doctors in places like the U.S., where the medical system is currently overwhelmed by the exponential growth of the novel coronavirus. But Khashan is not describing Gaza under COVID-19. She’s describing an average day at work in a medical system suffering under a 13-year blockade imposed by Israel that severely restricts the movement of people and resources in and out of the Gaza Strip.
Now, doctors and civilians alike are concerned knowing that Gaza’s medical system is unable to meet the needs of Gazans regularly, let alone if Gaza is to experience a coronavirus outbreak that mirrors China’s, Italy’s, or the U.S.’s, even by a small fraction.
“It’s an emergency even before corona,” said Khashan.
On March 22, the first two cases of the virus were detected among Palestinians in Gaza returning from Pakistan. By the time they arrived in Gaza, Hamas, which governs the strip, had already set up quarantine facilities for those traveling into the area. Those cases and the seven to follow were detected inside the quarantine centers.
Since then, Gaza’s doctors have been put on high alert in an attempt to stop the virus before it's too late. Khashan works in the obstetric and gynecology department, but new COVID-19 protocol in both Gaza and the West Bank means she asks every patient she sees if they’re experiencing any symptoms. “If I have a new patient coming from her home to ask about the problem behind her vaginal bleeding, I have to ask her if she is having a fever or chest pain, shortness of breath, or a cough,” she said. “And if any of those symptoms are positive, especially the question of if you are coming from outside Gaza or have you had contact with travelers, then I have to call the infection control committee.”
Today, at least 12 people in Gaza have tested positive for COVID-19 in Gaza. According to the Palestine Ministry of Health, six have recovered and the rest remain in an isolated corona health facility.
In some ways, Khashan’s concerns are similar to those facing doctors in the U.S.: there aren’t enough ventilators, not enough beds, not enough personal protective equipment (PPE), not enough hands, not enough hospitals. But in more ways, doctors in Gaza face COVID-19 challenges that will be unfamiliar to the majority of the world, even as other countries face their own extreme versions of this pandemic.
While the U.S. has approximately 52 ventilators per 100,000 people—which already falls well below the current need with COVID-19—Gaza has approximately three per 100,000 people. “The Ministry of Health urgently needs to be provided 100 ventilators and 140 ICU beds to achieve the first response to facing the Coronavirus outbreak, as we have only 63 ventilators and 78 ICU beds [in the Gaza Strip],” said the Palestine Ministry of Health in an April 1 statement.
Still, ventilators need electricity, and right now Gazans only have about eight hours of electricity per day, forcing hospitals to run on generators for the remainder of each day. Generators need fuel, and fuel is expensive. Long before coronavirus, electricity shortages have been to blame for several hospital and health center closures in the Gaza Strip.
“You may have electricity for ventilation, but you don't have electricity to light the surgery room,” Khashan said, recalling one instance where surgeons had to use their cell phones for light during a surgery. Often, she said, doctors must choose to allocate electricity to the resources and patients most in need.
The UN and several other organizations have developed a response plan to help doctors and civilians combat COVID-19 in Palestine, including both the West Bank and Gaza. The plan requires $34 million in aid divided among health care, education, food security, shelter, and access to washing services. So far, the plan is only 25 percent funded.
"You may have electricity for ventilation, but you don't have electricity to light the surgery room."
Despite the UN’s efforts toward aid, its position remains that it is Israel’s responsibility under international law to ensure Palestinians receive essential health services.
“The legal duty, anchored in Article 56 of the Fourth Geneva Convention, requires that Israel, the occupying power, must ensure that all the necessary preventive means available to it are utilized to ‘combat the spread of contagious diseases and epidemics,’” said Michael Lynk, the United Nations Special Rapporteur on human rights in occupied Palestine.
As the virus devastates crowded, well-off cities like New York, a main concern is Gaza’s density. Restricted movement in Gaza under the Israeli blockade has created one of the world’s most densely populated areas where nearly 2 million people live within 140 square miles. Both that density and the area’s poverty (Gaza’s unemployment rate is 47 percent) are barriers to social distancing and quarantine.
Khashan points out that asking people to self-quarantine and social distance isn’t particularly helpful when, for many, neither is an option. “Many of the people here work day by day,” she explained. “If a worker goes out to work in the morning, they get some money and then buy drinks and food for that day. They don't have savings, and they don't have another way to supply themselves with drinks and food.”
Khashan herself is having trouble self-isolating, despite working in a hospital where she knows her chances of exposure to COVID-19 are higher than the rest of the public. She lives with seven family members and shares a room with her two sisters.
“I'm afraid without using PPE I will be a carrier and bring [the virus] from the hospital to the house,” she said. “I don't have a choice except that I have just to face what is in front of me—to deal with that and to do my best.”