As conflict rages with the Israel-Hamas war, the growing crisis is straining an already overwhelmed global humanitarian system. In this Q+A, humanitarian health expert Paul Spiegel discusses the immediate health concerns for civilians in the Gaza Strip, the humanitarian response, and opportunities to stay informed and to advocate for humanitarian principles and international humanitarian law.

Spiegel is the director of the Center for Humanitarian Health at Johns Hopkins University and a professor of international health and epidemiology at the Johns Hopkins Bloomberg School of Public Health.

Note: This situation is fluid. Originally posted on the Bloomberg School of Public Health website, this Q+A was last updated on Oct. 20.

Can you provide some background on the humanitarian health crisis in Gaza leading up to now?

The health system in Gaza prior to this current crisis faced numerous challenges rooted in a complex geopolitical situation. The Israeli blockade of Gaza since 2007, when Hamas rose to power, combined with the intermittent conflicts that have occurred, has left the health infrastructure and services fractured, of varying quality, and with a limited number of specialized health services and technology.

The blockade has complicated the importation of essential medical supplies and equipment, and there are frequent shortages. Health care workers in Gaza have been incredibly resilient and dedicated despite these challenges. However, there remain human resource gaps, particularly in specialty areas like oncology, where Palestinians need to go outside of Gaza to receive some treatments.

The socioeconomic, political, and environmental factors in Gaza combined with these challenges to the health system culminate in a fragile health status of many Palestinians in Gaza. While there have been some improvements over the past decade, life expectancy is lower and infant and maternal mortality rates are higher compared to other areas in the region. There is a high prevalence of noncommunicable diseases, particularly diabetes, hypertension, and cardiovascular diseases. Mental health issues among children and adults are particularly high, driven by numerous factors including recurrent hostilities. Rates of acute and chronic malnutrition are unacceptably high, particularly among children. Lack of access to clean water and sanitation is persistently a challenge.

What are some of the greatest health concerns for civilians in Gaza related to the current crisis?

From a public health and humanitarian perspective, there are already massive red flags and major alerts as we discuss this situation right now, well before any potential ground invasion by Israel.

The complete blockade of Gaza does not allow for the importation of basic lifesaving services like water, electricity, food, and medical supplies into a densely populated and circumscribed area. Combined with bombing, a massive number of civilians being displaced, and attacks on health care facilities, this is a toxic brew for epidemics, exacerbations of existing illnesses, and increased morbidity and mortality.

The increases in trauma and injury due to bombings have already overwhelmed a challenged health system that is under attack. Epidemics, particularly of waterborne diseases like cholera, are of great concern. With respect to maternal and neonatal health services, which have the goal of ensuring safe deliveries, the World Health Organization (WHO) estimates there are 50,000 pregnant women in Gaza struggling to receive basic health services. Contributing factors include overwhelmed hospitals, movement restrictions, and lack of hospital space. Many civilians, particularly the elderly, who suffer from chronic noncommunicable diseases will not be able to continue with their care. Deaths will increase due to a lack of insulin and lifesaving cardiac medicines, the inability to continue with renal dialysis, and so many other issues related to lack of continuity of treatment. On top of all of this are concerns about COVID, influenza, RSV, and other infectious diseases.

What kind of humanitarian aid is getting through right now, if any? Who are trusted actors in this space?

To my knowledge, as we speak, there are talks of humanitarian aid getting in but nothing has come in yet. The WHO and other UN agencies, the International Committee of the Red Cross, nongovernmental organizations, and many other groups have truckloads of medical supplies and equipment, food, water, and other lifesaving essential items on the Egyptian side of the Rafah crossing waiting to be allowed to enter. My fervent hope is by the time this is published, some aid will have been allowed in. It is a humanitarian imperative.

Although there is currently no—or very little—humanitarian aid getting through to civilians in Gaza, what are international groups lined up to do? Is there any thought, at this time, to how the system should prepare to respond in the short and longer terms?

Sadly, conflict is not new in this region. There are active conflicts and skirmishes occurring in Syria, Sudan, Yemen, and Libya, to name a few. Governments, regional bodies, and the international community all have a variety of strategic plans, stockpiles, and surge teams ready to be implemented when feasible. However, insufficient funding, inadequate health workforce capacity, a serious lack of access, and insecurity remain formidable obstacles in the short term.

Without political will to address the underlying causes of these conflicts, they will remain protracted; the Israeli-Palestinian conflict being one of the longest unresolved conflicts in the region, and possibly the world. In the longer term, there will be a need to rebuild the health structure in Gaza, and to address the underlying socioeconomic, political, and environmental issues that so negatively affect the health of people living in Gaza, as I mentioned previously. The challenges are enormous, both in terms of rebuilding health infrastructure and workforce, addressing the massive mental health needs, and ensuring long-term rehabilitation for the thousands of trauma victims. These conflicts have short- and long-term impacts on the health of all populations involved.

Given that this situation will undoubtedly become more perilous for civilians, and the fact that there are many other major humanitarian crises playing out across the globe, what’s the state of humanitarian systems and their ability to address all of these overwhelming needs?

I published an article six years ago in The Lancet entitled “The humanitarian system is not just broke, but broken.” I mentioned at the time that the number of humanitarian emergencies was unprecedented and that to adapt to these challenges, the humanitarian system must do a few things:

1. Operationalize the concept of centrality of protection, which means including human rights at the core of policies and interventions for persons affected by conflict or natural disasters.

2. Integrate affected persons into national health systems by addressing the humanitarian–development nexus. This takes the long view of the health of refugees and internally displaced persons while also considering the impacts on the host country.

3. Remake, and not simply revise, leadership and coordination towards a more streamlined, and less bureaucratic, approach to responses of humanitarian emergencies.

4. Make interventions efficient, effective, and sustainable. Protracted situations are becoming the norm, so the need to invest in longer-term solutions is clear.

I wrote this even before a global pandemic and the multitude of other large-scale crises like Ukraine, Sudan, Ethiopia, Afghanistan, Venezuela, Nagorno-Karabakh, the Sahel, and, sadly, so many more. This was before a massive surge of populism and anti-migrant and anti-refugee sentiment. And it was before concerted campaigns of disinformation and deep fakes.

The humanitarian system in its current form is overwhelmed and not fit for purpose, and is in need of a structural reform, as is humanitarian financing and its links with development. When you factor in the urgency of the climate crisis and prevailing political instabilities, I am quite apprehensive about the future.

Everyone is concerned about civilians in this conflict. What can people do to help?

It is wonderful and hopeful that people want to do something to aid innocent civilians in this conflict in Gaza and Israel.

First, let me start with what is not helpful. Please don’t gather goods and medical supplies and try to send them to Gaza or Israel. It adds more bureaucracy, administration, time, and human resources to the UN and NGOs who are so very busy trying to address a dire humanitarian crisis. Also, we do not need well-intentioned health care professionals who have not been trained in humanitarian health and have not spent time abroad in such dangerous situations volunteering to go to conflict zones. Your willingness to help is admirable, but as with sending in-kind goods, it can actually slow down and even cause harm in such contexts.

There are so many constructive ways that well-meaning people can help civilians in all regions who are affected by this conflict. First and foremost, people should read trusted sources and diverse, nuanced viewpoints about this crisis, as well as the myriad of other forgotten emergencies out there. There is a great deal of misinformation, and people should attempt to be as well-informed as possible.

People can advocate that civilians, wherever they reside, should not be used as pawns in this or any conflict. Individuals can steadfastly declare that attacks on health care workers, health facilities, and schools must not occur, and that there must be accountability for perpetrators. And finally, people can advocate with their elected officials to ensure that humanitarian principles and international humanitarian law are respected by all parties to this conflict.

Finally, if you are able, it is always helpful to donate to trusted organizations such as the International Committee of the Red Cross.