Healthcare is a unique issue in international politics and discussions of modern civilization. As an institutional entity, it has both a substantial and direct implication regarding the very existence of human populations. That’s in contrast to markers such as employment, GDP, or literacy that have effects that are slightly harder to trace out. Indeed, the authors 2010 World Health Report recognized that “promoting and protecting health is essential to human welfare and sustained economic and social development” and that people “rate health one of their highest priorities” (1). As a majorly accepted sentiment, it becomes morally difficult to justify institutional healthcare inequalities if we choose to believe in principles of democracy and Rawlsian equality of opportunity.
If, as a nation, we impose economic sanctions on another country as a method of foreign policy, it’s okay for that nation’s economy to suffer because it puts pressure on the government and state leaders to capitulate. What you’re not allowed to talk about are the direct outcomes on the population because the point is to get the boogey man—Saddam or Osama—but not to cause a humanitarian crisis characterized by the starvation of children in, say, Afghanistan (2). Unfortunately, severe economic decline and mass suffering are inexorably linked as is clearly demonstrated by the Palestinian condition.
Starting in 2009, one of the world’s leading medical journals, The Lancet, began publishing a series of studies and commentaries concerned with the socioeconomic condition in the occupied territories. The chief editor of the journal, Richard Horton, recognized that “since 2000, the occupied Palestinian territory has experienced increased human insecurity, with the erosion and reversal of many health gains made in earlier years” and that “these setbacks, together with the latest Israeli air and ground attacks on Gaza, have plunged the region into a humanitarian crisis” (3). Indeed, a February 2012 poll by the Palestinian Center for Public Opinion reported that 54.7% of Palestinians are concerned about their subsistence of themselves and their family. Furthermore, when asked about their main present concern, 39.6% said it was employment and 22.4% said it was security (4).
The reason for their bleak outlook is pretty straightforward, let’s just look at the facts. The aftermath of the Second Intifada and the blockade of the Gaza Strip left the population of 1.7 million in a devastated state. In 2008, 37% of the active workforce in Gaza was unemployed and 74% of the population lived below the poverty line of $3.15 per person per day. Unemployment in the West Bank was 19% and 40% lived under the poverty line. Though physical, institutional, and trade restrictions imposed on the Occupied Territories since the Oslo accords had been deteriorating the internal Palestinian economy, foreign aid allowed for continued development (32% of GDP according to the World Bank) (5). However, the situation collapsed upon the popular election of Hamas: “Diplomatic ties and international donor funding were cut, and Israel withheld Palestinian tax revenues, which together form about 75% of the budget of the Palestinian National Authority.” (6).
Health outcomes also deteriorated sharply as a result of economic penalties and restrictions. Electricity and cooking gas to Gaza was heavily diminished which subsequently “disrupted the operation of water and sewage pumps throughout the Gaza Strip.” In addition to continual shortages of medicines and medical supplies, a WHO report found that “medical devices are often broken, missing spare parts, or out of date” (7). Amnesty International’s 2011 Report revealed that the infant mortality rate in the occupied territories is 23/18 (m/f) per 1000 in contrast to 6/5 in Israel. Furthermore the life expectancy in the territories is 72.9 years as opposed to 80.3 years in Israel (8). Proper access to healthcare has also been severely impaired by the stringent restriction on travel outside of the occupied territories. Reports by Physicians for Human Rights revealed an increase in the medical referrals outside of Gaza coupled with a decreased in travel permissions allowed for these cases by Israeli officials (9). The population inexorably suffers.
The fundamental barrier Palestinians face in attaining healthcare is ubiquitous: inability to afford high costs. There is no realistic way of implementing a system of pooled risk to decrease up-front costs and the distribution of healthcare resources (including personnel) among the sick is extremely inefficient. Because of the stipulations of the Israeli occupation, the “Palestinian National Authority is expected to perform as the government of a state while lacking control over its borders, basic resources, and many of the social determinants of health” and “vague institutional arrangements have hindered the establishment of a proper governance system” (10).
Modern medicine is built upon basic principles of inter- and intra- state trade. This is in sharp contrast to an advanced profession such as law where an expertly trained professional can provide legal counsel just about anywhere and to anyone. In addition to the physician’s knowledgebase and skill set, he/she requires material goods and resources such as medicines and biomedical equipment. The internal economy of Palestine is deeply impoverished and exchange with external parties is severely hindered by check points, roadblocks, and blockades. There are no economic and logistical frameworks to get patients what they need.
The bottom line is that the population suffers due to external forces beyond their control (and desire as revealed by the polls). A crippled economy left the people without jobs or an infrastructure for societal development: they’re stuck. In the ghetto that is Gaza Strip: “social solidarity and resilience have nurtured the Palestinian health response to occupation.” However, in light of continued political and economic degeneration, “the social fabric of Palestinian society is eroding (11).” Ordinary Palestinians are completely disenfranchised. Even if they were to engage in popular demonstration which has been used globally to achieve egalitarian health objectives (12), the Palestinian Authority does not have the capacity to react significantly in any way. If the only parties that enter the discourse are Fatah, Hamas, Israel, and the United States, then health outcomes will decline. Poor healthcare has become an effective means of nonviolently undermining a population. Sadly enough, the same strategy was employed in Apartheid South Africa.
Ravi Katari works for a health law firm in Washington D.C. He graduated from the University of Virginia with a degree in Biomedical Engineering.