When the COVID-19 pandemic struck worldwide, humanitarian organizations in the Gaza Strip sounded the alarm, warning against a health catastrophe that could hit tens of thousands of people. The Strip's high population density, weak healthcare system, and lingering crises did not bode well for efforts to mitigate the health impacts of a possible virus outbreak. Now fears are greater than ever as the first cases of COVID-19 were detected among members of the community in late August, triggering local authorities to impose a new lockdown.
To make matters worse, August saw an escalation of violence between Israel and Hamas, with Israel tightening the blockade it imposed on Gaza following the rise to power of Hamas in 2007. Since then, three wars and repeated outbreaks of violence have worsened conditions for civilians. In addition, a chronic shortage of humanitarian funds, exacerbated by United States funding cuts since 2018, has made access to some of the most basic services a challenge.
Nearly 2 million people live in the Strip's 139 square miles, many in crowded refugee camps. At nearly 13,000 people per square mile, Gaza is one of the most densely populated areas in the world. Under any circumstances, social distancing in the enclave would be a formidable challenge. More than 70 percent of Gaza's residents are registered with the United Nations Relief and Works Agency (UNRWA). The Agency and its international and Palestinian partners play an essential role in providing food, water, shelter, healthcare, education, and even jobs for a largely destitute population.
In light of Gaza's vulnerability, authorities and healthcare and humanitarian workers have focused their efforts on prevention. For several months, these efforts have spared Gaza the worst of the coronavirus. However, the detection of 12 COVID-19 cases in late August among members of the community could represent the beginning of more hardship for a population that has already suffered tremendously. As of September 3, the number of local cases had risen to 463. Gazans not only face grave and direct risks resulting from further exposure to COVID-19, but from the virus' economic shocks that could dramatically impact their already limited access to critical supplies and services.
Gaza Under COVID-19: Containment and the Impact of the Pandemic
The Initial Response to the Pandemic
Gaza's inadequate living conditions, dilapidated infrastructure, and weak healthcare system made it ill-prepared to face a COVID-19 epidemic. The enclave has no more than 78 functioning intensive care beds, all of which were in use as of this writing, and even fewer ventilators. Aware of these feeble capacities, authorities, health professionals, and humanitarian workers in Gaza have made prevention a priority. In March and until the end of May, the Hamas government imposed strict measures, such as prohibiting social gatherings, and closing mosques, wedding halls, restaurants, coffee shops, and all non-essential businesses.[i]
Furthermore, Gaza's Ministry of Health enforced a two-week quarantine on all travelers entering from Rafah in Egypt or the Beit Hanoun (Erez) crossing in Israel, which was subsequently extended to three weeks. It also suspended all elective surgeries and medical procedures. Additionally, the Hamas government prepared centers for quarantine, isolation, and treatment. Initially, poor conditions in quarantine areas were improved, thanks to the help of humanitarian organizations. Quarantine also included all medical and security staff who came in contact with returnees.[ii]
For its part, UNRWA closed all its schools in Gaza and implemented measures for social distancing and better hygiene. In its 22 health centers, the Agency separated people with respiratory illnesses from people with other illnesses. In addition, UNRWA redesigned its food program, which benefits 1.1 million people, switching from collective distribution centers to a home delivery model. International non-governmental organizations (INGOs) and Palestinian NGOs followed the Agency's lead, supporting efforts to raise awareness among the local community.[iii]
In addition, the World Health Organization (WHO) and other international and regional partners delivered 20,000 items of personal protective equipment (PPE) in the Gaza Strip, 140 test kits with the capacity to perform 14,000 tests, and 3 PCR machines.[iv] Finally, humanitarian organizations provided a wide range of non-food items and continued support through the provision of food and other services in the quarantine facilities.[v] However, shortages remain, and in the event of a local outbreak, Gaza will need a significant increase of ventilators, PPE, and testing kits.
According to UNRWA's director in Gaza, "a combination of good luck and good measures," has resulted in what seems to be a relatively small number of COVID-19 infections. As of September 3, 581 confirmed cases had been detected, with five deaths reported.[vi] However, although most cases were initially among returnees who were systematically quarantined, twelve cases of community transition were reported in late August, triggering fears of an outbreak that would be difficult to contain.[vii] Following this detection, the Hamas authorities imposed a new lockdown. By early September, containing the virus seemed increasingly difficult, with the number of positive cases inside Gaza reaching 1,024 as of September 8.[viii]
Paradoxically, the blockade of Gaza may have helped delay the virus from spreading in the Strip. The tightly controlled movement in and out of Gaza allowed for early detection of COVID-19 cases and a mandatory quarantine. A journalist in Gaza explained, "For once, the siege played in our advantage. We did not have to deal with the same challenges faced by the rest of the world. We did not have unchecked travelers who spread the virus among people. We don't have an airport nor a seaport, which made monitoring all movements much easier."[ix] However, as the virus reaches local communities inside the Strip, greater measures should be implemented to mitigate its potential outbreak.
Prevention Protocols and Social Norms
In June, the Hamas government put an end to the state of emergency and re-opened non-essential facilities. And by late July, life was virtually back to normal with only some slight COVID-19 preventive measures to be seen in the Strip.[x] Most people did not wear face masks, maintain physical distancing, or comply with sanitary requirements, residents in Gaza told Refugees International. In early August, more than 500,000 students went back to schools, including nearly 300,000 to UNRWA-run schools. However, students "were not required to wear masks or keep distancing, but teachers at [UNRWA] schools poured sanitizers on students' hands."
The fact that, for the first six months, the virus detection has been confined to quarantine centers may well have given many a false sense of security. UNRWA's Gaza Director told Refugees International, "I think the worldwide phenomenon is that, if you are not directly affected, it is difficult to implement strict measures. It is a human instinct to feel the danger only when it hits close to home. If not, you just think it is someone else's crisis."
One potential catalyst for an COVID-19 outbreak in Gaza is a low rate of adherence to prevention protocol combined with highly social community life. As an aid worker in Gaza warned, "Our social and cultural practice -- with a lot of mingling involved -- as well as overcrowding in public places due to the population density, makes it that if one person within the community contracts the virus, they risk passing it to tens of others."[xi] "Even if as low as 1,500 people contracted the virus," added a head of a humanitarian organization, "Gaza would not be able to cope."[xii]
The Economic and Social Impact of COVID-19
Even before the August outbreak, Gaza was reeling under the weight of last spring's three-month lockdown and the pandemic's wider global economic impact. The renewed lockdown is likely to worsen the situation.
Over the initial months of the pandemic, many businesses, especially small enterprises, were not able to withstand the burden of months of closure, and many had to shut down permanently. According to the head of the General Federation of Trade Unions in Gaza, between mid-March and mid-July, nearly 4,000 people in Gazalost their jobs, at least 50 factories closed their doors, and more than 10,000 taxi drivershave seen a large reduction in their income. The pandemic has also pushed a greater number of households into poverty and food insecurity, with an increase of at least 10 percent in the poverty rate according to the World Bank.
Schools and universities remained closed for several months due to COVID-19. Prolonged power cuts, which in turn affected access to the Internet, made virtual learning extremely challenging. Both teleworking and tele-education have put additional strains on Gaza's infrastructure. Many students have not paid tuition fees. A university's vice-president in Gaza explained, "Thirty percent of students dropped out this semester, and only 10 percent paid the full tuition fees. The university was unable to pay staff salaries." Already, educational staff are poorly paid, and some teachers have not been paid for the past six months due to lack of funding.[xiii]
COVID-19 has exacerbated the sense of despair and heightened social problems in the Strip. Humanitarian workers report a noticeable increase of gender-based and other forms of violence, as well as depression, drug use, and self-harm.[xiv] In the absence of reliable data, it is difficult to evaluate the extent of these behaviors. Information remains largely anecdotal. Yet, most Refugees International interlocutors referred to a noticeable increase in suicide, although suicide is a taboo in the largely religious Gazan society.
To be sure, mental health remains a great concern. Even before COVID-19, 30 percent of the first diagnoses in UNRWA's health centers were related to mental health, explained UNRWA's Gaza Director. The pandemic only heightens concerns about mental health. However, limited funding is hindering the ability to upgrade mental health and psychosocial support (MHPSS) services, despite the ever-increasing need for it.[xv] As of September 2, 90 percent out of the $5.94 million to respond to MHPSS in the occupied Palestinian territories (oPt) remained unfunded.[xvi]
Acute on Chronic: The Legacy of the Blockade and War
In Gaza, the COVID-19 pandemic comes against the backdrop of renewed violence and increased access restrictions. For the past 13 years, these restrictions have worn out the Strip's population, its infrastructure and healthcare sector---and the population's capacity to address fundamental shocks such as the COVID-19 pandemic.
By land, the Strip is connected through the Rafah crossing with Egypt and the Beit Hanoun (Erez) with Israel, in addition to the Kerem Shalom (Karam Abou Salem) and the Salah el Din commercial crossings with Israel and Egypt respectively. The movement of people and goods through these crossings is tightly controlled by Israeli and Egyptian authorities. Other crossings remain closed. Between 2007 and 2014, Israel imposed a broad blockade on Gaza, making the entry of dual-use materials, including some construction supplies, extremely challenging, which significantly impeded the Strip's infrastructure development and the provision of humanitarian assistance.
In the wake of the so-called Operation Protective Edge (the 2014 Gaza war), Israel eased but did not completely lift the blockade. It created a mechanism coordinating the entry of building materials and goods, agreed upon by its government and the (West Bank-based) Palestinian Authority (PA) and monitored by the United Nations. However, this process, which regulates the entry of building materials, remains very burdensome, requiring multiple approvals from various Israeli governmental bodies and the frequent submission of numerous documents. This often causes significant delays to repair, rehabilitation, or reconstruction projects.[xvii]
Moreover, Israel has intermittently suspended the entry of cement, rubber tires, and other supplies. Israel's attacks on the Strip's infrastructure and repeated bombing of facilities in the agriculture, water, energy, and health sectors have contributed to the deterioration of the humanitarian situation. Reconstruction efforts have been complicated by the blockade and by construction permits' delays or denials.
In recent weeks, Israel has once again tightened the blockade. For much of August, the security situation in Gaza deteriorated as Israel bombed the Strip. The bombings came in response to incendiary balloons, and less frequently rockets, launched from Gaza into Israel, which burned swathes of Israeli farmlands. Israel also banned the entry of construction materials and fuel in Gaza. This in turn has forced the enclave's only power plant to shut down. The closure has also limited the entry of goods to medicine and food. On August 31, following a Qatari-brokered ceasefire between Hamas and Israel, Israel started reallowing the entry of fuel and other recently banned materials into Gaza.
The Impact on the Economy and the Health System
Over the years, the blockade has deepened poverty in Gaza. The current poverty rate stands at over 80 percent -- up from 39 percent in 2011. According to the Palestinian Central Bureau of Statistics, nearly 80 percent of private sector workers receive less than half the 1,450 Israeli Shekel (approximately $430) minimum monthly wage. In 2019, unemployment was estimated at more than 50 percent in general and 70 percent among youths. "Every year, thousands of young people graduate from schools without any prospect for jobs," a journalist in Gaza lamented. More than two thirds of Gaza's population are unable to provide the minimum requirements for a decent living and largely rely on humanitarian assistance.
Like the economy, Gaza's healthcare system has suffered significantly under the blockade. The restrictions, combined with periodic hostilities and a lack of funding, have contributed to the decay of medical infrastructure and shortages of drugs, equipment, supplies, and personnel. In 2018, the funding gaps and power blackouts forced a number of hospitals and clinics to close. The subsequent U.S. decision to cut UNRWA's and the PA's funding has further weakened the enclave's healthcare system. Even before the COVID-19 outbreak, several organizations and UN agencies had warned that Gaza's healthcare system was "on the brink of collapse." The recent Israeli ban on fuel and resulting closure of Gaza's only power plant could cause power cuts in hospitals with "dangerous repercussions" on patients' lives, warned officials in Gaza.
Moreover, the blockade and recurrent violence have led to a significant exodus of doctors. Those who stayed often lacked opportunities for specialization, training, or exposure to the latest inventions and developments in the medical field. This is largely due to the fact that travel in and out of the Gaza Strip remains highly restricted and daunting, leaving a deeply weakened and overstretched medical personnel.
Although the Gaza Strip has never figured seriously in any recent debate on de jure annexation of parts of the West Bank, the annexation debate has had serious humanitarian implications in the Strip. The 1992 Oslo peace agreement between the Palestinian Liberation Organization (PLO) and Israel divided the West Bank into 3 areas: Areas A, B, and C. Area C, comprising more than 60 percent of the West Bank, was placed under Israeli military control, awaiting its returning to a full Palestinian control. However, Israel has continued to expand Israeli settlements in this area.
In recent months, concerns over annexation peaked when Israeli Prime Minister Benjamin Netanyahu announced a plan to formally annex 30 percent of the West Bank's Area C. In response, in May, the PA ended all agreements signed between the PLO and Israel. This included the ending of coordination procedures to allow medical exit permit holders to leave Gaza through the Erez crossing. The PA also refused to receive additional applications for medical exit permits. An alternative WHO-led temporary mechanism to facilitate the transfer of patients' documentation to Israeli and Palestinian authorities has been delayed. Some NGOs stepped in to secure medical exit permits for patients in Gaza. However, Israeli approvals of these permits remain limited.
Every year, tens of thousands of Gazans apply for medical exit permits through the PA to travel via the Erez Crossing to seek treatment in the West Bank or Israel that is unavailable in Gaza. The permit system for medical patients has been tightly controlled by Israel in recent years and relatively few permits are issued. These Israeli restrictions, coupled with the PA's decision and the crossing closure due to COVID-19, have hampered access to life-saving healthcare for hundreds of Gazans resulting in loss of lives among non-COVID-19 patients.
In response to the annexation announcement, the PA has also rejected the transfer of tax revenues collected on its behalf by Israel. As per the Oslo peace agreement, the government of Israel taxes Palestinian imports and exports, all of which are channeled through Israeli customs, and withholds income taxes from Palestinians employed in Israel. Israel then makes payments to the PA. The latter largely relies on these funds to pay government employees and provide some services to Gaza including electricity, pharmaceutical supplies, and medical equipment.
Having refused the transfer of tax revenue, the PA stopped paying for Gaza's electricity, thereby exacerbating the already acute power shortage in the Strip. The PA also stopped paying the salaries of an estimated 16,000 civil servants in Gaza. In August, following a deal with the United Arab Emirates to normalize relations, Israel announced its suspension of the annexation plan. However, the normalization arrangement has been followed by increased tension between the PA and Israel, and this does not bode well for those in Gaza in need of humanitarian assistance.
The Donor Response
Funding Response to COVID-19
During the initial phase of the global pandemic, the UN and humanitarian organizations launched a $41.9 million appeal for a joint West Bank and Gaza COVID-19 Response Plan, of which nearly $12.5 million was designated for Gaza; the appeal was subsequently increased to $49.6 million. As of August 11, 73 percent of the amount requested in the Response Plan has been raised.
The COVID-19 appeal remains relatively well funded compared to the core and emergency UNRWA budgets funding, raising concerns among the humanitarian workers and UNRWA officials that the pandemic response might crowd out other much needed-funding.[xviii] Still, given the emerging cases inside the Strip, COVID-19 funding needs in Gaza will almost certainly rise, which in turn will require the support of donors.
Chronic Shortfalls and the 2018 U.S. Aid Cutoff
The relatively strong performance of the UN COVID-19 appeal belies the recent history of donor funding for Gaza. It is important to remember that more than 80 percent of Gaza's residents rely on humanitarian aid. UNRWA and its partners play an essential role in providing lifesaving assistance to the Strip's largely destitute population. Together, they provide food aid, essential medicines, a wide network of schools, water, and sanitation operations. In recent years, funding has fallen due to a "growing donors' fatigue especially as the situation doesn't change and the economy has no capacity to regenerate itself."[xix]
In particular, Gaza is suffering from repercussions of the United States' 2018 politically motivated decision to stop all Palestinian funding. In 2018, Refugees International and other NGOs publicly opposed the Trump administration's curbing of aid to the Palestinians. In a January 2018 letter, they also expressed deep concerns about politicization of humanitarian aid, and the linking of such assistance to Trump administration political objectives. In a subsequent public letter, they warned that "[h]umanitarian aid should never be used as a political bargaining chip."[xx] UNRWA is currently facing its third year without U.S. financial support. The U.S. decision has left a massive funding gap and has had a corrosive effect on the Agency's provision of essential services to Gaza.
Some donor countries have stepped in to fill some of the funding shortfall, including countries in Europe and the Gulf. However, Gulf contributions remain unpredictable. Gulf country pledges to UNRWA's Program budget reached nearly $200 million in 2018, but significantly dropped the next year to less than half. "The reality is that there is not a replacement for the funding from the U.S. UNRWA will now never reach a level of financial stability," explained the director of UNRWA in Washington DC.
In late June 2020, donor countries held an Extraordinary Virtual Ministerial Pledging Conference to bridge UNRWA's $400 million funding gap. However, the conference was only "a partial success," said UNRWA's Director in Gaza, as the pledges reached nearly 50 percent of the Agency's core funding.
Conclusion and Recommendations
The population in Gaza is living a double quarantine. The first is due to COVID-19. The other results from Gaza's daily reality under the blockade. People inside the Strip find themselves trapped in increasingly unlivable conditions.
To help Gaza cope with a looming COVID-19 outbreak:
Gaza authorities should enforce health and safety requirements. They should provide guidance to citizens, businesses, and institutions on preventive measures against the spread of COVID-19, including limiting the number of people in closed areas, maintaining physical distancing, and wearing masks.
In light of concerns that best practices have not always been observed within institutions of authority over health-related issues, UNRWA, international, and Palestinian organizations should lead by example through wearing facemasks and maintaining physical distancing. They should also continue to conduct awareness campaigns about the prevention of COVID-19 and warn local communities about the risks of a premature total relaxation of preventive measures.
In light of existing and likely future shortfalls, donor governments and the WHO should provide additional ventilators, PPE, and testing kits to help Gaza cope with a potential coronavirus outbreak.
To alleviate the pre-existing humanitarian crisis in Gaza:
Israel should commit to significant and substantial measures to ease the entry into Gaza of building materials intended for the humanitarian sector. For instance, Israel could designate a single governmental agency to grant a one-time up-front approval for construction projects.
In general, Israel and Egypt should commit to freedom of movement for Gazans, and, in particular, relax movement restrictions on Gazans who are playing a key role in promoting key humanitarian objectives---particularly medical personnel, teachers, key service providers, and seeking professional training and advancement in these sectors.
Israel should ease restrictions on the medical permits system, to provide Gazans with access to life-sustaining and life-saving treatment in the West Bank or Israel that is unavailable in Gaza.
The Palestinian Authority should resume coordinating the exit of permit holders from Gaza through Erez crossing and receiving new applications for medical permits.
With no further delay, and until the Palestinian Authority resumes the coordination of medical exit permits, the WHO, with the cooperation of Palestinian and Israeli authorities, should immediately begin to facilitate the transfer of patients' documentation to Israeli and Palestinian officials to ensure Gazans' access to life-saving healthcare.
The European Union should continue to support UNRWA through predictable funding to the Agency's Program budget, in the form of a multi-year financing commitment, at a level commensurate with prior years (about EUR 100 million), in addition to supporting emergency responses.
Gulf countries should commit to at least $200 million yearly contribution to UNRWA's core budget, as they did in 2018, in addition to emergency funding. The yearly contribution can be reviewed periodically depending on needs.
The Trump administration should reverse its 2018 decision to stop UNRWA funding as well as other forms of funding to the occupied Palestinian territories.
Donor countries should prioritize funding of the medical sector, including the provision of medical equipment and supplies, and professional trainings and specialization.
Donors should fill the $5.3 million gap required to respond to mental health and psycho-social support needs in the occupied Palestinian territories.
[i] Phone interviews with representatives of international and Palestinian NGOs and UNRWA, journalists and activists in Gaza, June-July 2020.
[ii] Phone interviews with representatives of international and Palestinian NGOs and UNRWA, journalists and activists in Gaza, June-July 2020.
[iii] Phone interviews with UNRWA officials in Gaza and Washington DC, June 2020.
[iv] Email correspondence with UNRWA Gaza Director, August 3, 2020.
[v] Phone interviews with representatives of UN, INGOs, and Palestinian NGOs in Gaza, June-July 2020.
[vi] COVID-19 Updates in the Gaza Strip, Ministry of Health, September 3, 2020.
[vii] Phone interviews with a humanitarian worker and a health professional in Gaza, August 25, 2020.
[viii] Email correspondence with UNRWA's officials in Gaza, September 3, 2020.
[ix] Phone interview with a journalist in Gaza, 25 June 2020.
[x] Phone interviews with residents in Gaza, July 2020.
[xi] Phone interview with a representative of a Palestinian NGO in Gaza, June 20, 2020.
[xii] Phone interview with the director of an international NGO in Gaza, July 5, 2020.
[xiii] Phone Interviews with journalists, activists, INGOs and NGOs representatives in Gaza, June-July 2020.
[xiv] Phone Interviews with representatives of UNRWA and INGOs and NGOs in Gaza, June-July 2020.
[xv] Phone Interviews with representatives of UNRWA and INGOs and NGOs in Gaza, June-July 2020.
[xvi] Email correspondence with UNRWA officials, September 2, 2020.
[xvii] Phone interviews with representatives of Palestinian and international NGOs, journalists, and activists, June-July 2020.
[xviii] Phone interviews with representatives of UNRWA and Palestinian and international NGOs, July-August 2020.
[xix] Phone interview with the International Crisis Group's Senior Analyst in Jerusalem,
[xx] Also see Daryl Grisgraber, "The Thousand Cut: Eliminating U.S. Humanitarian Assistance to Gaza", Refugees International, November 2018; https://www.refugeesinternational.org/reports/2018/11/2/the-thousandth-cut-eliminating-us-humanitarian-assistance-to-gaza