Health Care in the Gaza Strip
Mr S A Khan and Mrs A Drakou
Arriving in the Gaza Strip, early March 2009 as part of a surgical trauma unit (Mobile International Surgical Teams, MiST Foundation) was a tremendous relief. We had spent a nervous week in Al Arish in Egypt, unsure whether our team would be allowed access to Gaza through the Rafah crossing. Our urgency and need to enter was to help in the humanitarian crisis after the 2008/2009 hostilities in the Gaza Strip, killing many and maiming numerous more Gazans. MiST Foundation, is a UK-based surgical charity, specialising in the management of trauma and limb injuries following natural and man-made disasters (www.mistngo.org). The first MiST unit into Gazaf following the hostilities arrived in February 2009 and set up links with Nasser Hospital, in Khan Younis situated in southern Gaza.
During our first stay in Gaza of 2 weeks in March 2009, we were shown great respect and genuine warmth from the people of Gaza. The devastation was plain to see, as were the problems with the Gazan health service. During this visit, the Ministry of Health (MOH) asked for my assessment of Orthopaedic services in the Gaza Strip.
The Palestinian health system has suffered for many years from scarcity of resources, polarity, lack of coordination and integration, and lack of strategic direction and leadership. This led to a fragmentation of services, increasing the vulnerability of population and fragility of the health institutions. Since June 2007, the siege has intensified on the Gaza Strip greatly harming the health care system, which was already dysfunctional. Many services and life-saving treatments were not available to Palestinians inside Gaza. Following the hostilities, the already fragile health care system in Gaza toppled into free fall, creating an acute-on-chronic crisis (EUNIDA, Final Report 2010).
With the deterioration of the political situation and the blockade there was a worrying deterioration in many health care indicators (UN OCHA OPT report August 2009). The supply of medicines, medical disposables and equipment to Gaza was significantly delayed or non existent. The blockade was destroying the public service infrastructure in Gaza. Hospitals could not generate electricity to keep lifesaving equipment working or to generate oxygen. As a result of fuel and electricity restrictions, hospitals were sometimes experiencing power cuts lasting for 8-12 hours a day. Frequently, a 60- 70% shortage was reported in the diesel required for hospital power generators. Furthermore, increasing use of hospital generators had led to the need for maintenance and replacement, which was mostly impossible given the lack of spare parts or new equipment in Gaza. MiST units have had to operate in theatres illuminated by mobile phone lights due to a power failure!
The Gazans’ healthcare had dramatically deteriorated on two levels: the provision of health services within the Gaza Strip and access to treatment outside Gaza.
After my review of the orthopaedic services in Gaza for the MOH, there was clearly a lack of suitable qualified and experienced surgeons. The MOH hospital facilities were lacking with numerous occasions of equipment failure and inadequate hardware to provide a trauma and elective service. The private sector in Gaza, in contrast, worked very efficiently. The only working MRI scanner was situated in a very plush private clinic. The MOH’s MRI scanner kept breaking down, with the same technicians running both services.
The population of the Gaza Strip is approximately 1.5 million with the majority leading an agrarian lifestyle. Of these, 50% are less than 12 years old (WHO consensus 2007, Palestinian Central Bureau of Statistics, 2009). The recommended ratio of Orthopaedic Consultants per population is 1 per 20, 000 (British Orthopaedic Association). Thus, a total of 75 Orthopaedic Consultants, with their respective teams of junior doctors and trainees, are required for the population of the Gaza Strip.
Currently, many of the surgeons in Gaza both work in MOH and NGO hospitals, so the true number of specialists is overestimated in the Gaza Strip. The number of Orthopaedic Consultants in the Gaza Strip is 10 (personal communication, MOH 2010), so a deficit of 65 trained Orthopaedic surgeons exists.
The lack of up to date surgical equipment leads to the inevitable complications seen by using inferior implants in treating common fractures. Much of the equipment donated by countries and institutions to Gaza ends up in 3 huge warehouses. Gaza is becoming a dumping ground for old, out of date kit sent there as good will and solidarity. Donors should ask what is needed instead of sending their old, unused equipment to Gaza. MiST has sent over $400 000 worth of trauma kit. This is being used in the main hospital in Gaza and the trained personnel can teach others in the use of this equipment.
This lack of equipment combined with an Orthopaedic workforce, with a medical education obtained in 14 different countries, leads to heterogeneity in patient management.
The University of Gaza understood that a problem existed in the teaching and training of medical staff in the MOH hospitals. Thus, with the establishment of the Gaza Medical School in 2004, the first medical students are graduating locally, with a more rounded education but lacking in clinical skills. The Medical School in Gaza is an impressive building, with the state of the art facilities and full of eager, well educated students with a hunger for knowledge.
Many of the medical students knew their theory very well, but in patient examination the students were deficient. This was due to the lack of recognised local clinical educators. Moreover, the students’ theory did not match the practise due to lack of clinical leadership in the Gazan hospitals. For example, on a ward round, I asked a medical student what was wrong with a patient’s radiograph of a leg. She instantly told me there was no date, name or side on the X-ray film, so we could not be sure whose x-ray this belonged to.
The lack of clinical leadership and resources is a dangerous combination for the local health care system.
MiST proposals to improve orthopaedic care in the Gaza Strip, was warmly received by the MOH. MiST suggestion of improving not just the Orthopaedic training of surgeons by visiting teams and hands on surgery, but of the allied health care professionals and medical students would be beneficial in the long term. This educational goal could be achieved by in-house lecturers on sabbaticals from the UK, visiting medical teams and e-learning, all to be provided by MiST and its collaborators.
In June 2009, I was invited back to the Gaza Strip as a visiting Professor of Orthopaedics and head of Department at Nasser Hospital in Khan Younis. My NHS hospital in Manchester would not grant me unpaid leave, so I resigned from my post and in April 2010 went to southern Gaza for a period of 9 months. Returning to Gaza was a privilege and an honour and even more so, now that the MOH seemed to welcome change in the system for the better. My brief was to improve the hospital junior education and training and we soon set off to work with a renewed vigour and cooperation from the staff at Nasser Hospital.
The working week in Gaza starts at 8am and finishes at 2pm for 6 days a week. This initiative was implemented by the MOH and has caused much resentment. The initiative was to help improve efficiency and patient care, but back-fired as this action led to the staff becoming disillusioned at having to work 6, instead of 5 days a week. Many of the staff at Nasser Hospital remained after work to do an extra operating list with me from 2 to 5pm, once a week. This initiative was due to the local hospital administration and not the MOH. This extra operating list allowed me to improve the throughput of complex orthopaedic cases.
The MOH would not provide MiST any extra operating lists, even though the database of cases was increasing. Patients were in need of a joint replacements or corrective limb surgery, an expertise MiST was providing locally in Gaza but no facilities to perform such procedures. Eventually all these patients would need to be referred abroad for further management, at a cost to the West Bank authorities and a personal cost to the patients. I have witnessed patients made to wait hours at checkpoints and border crossings before they are allowed through. Both humiliating and tiring for these patients going for treatment abroad.
Other NGO’s were allowed to operate out of hours, as they were paying the MOH for a presence in a Gazan hospital.
As the weeks went by in Gaza, it became clear to us that the MOH had initially said they wanted an improvement in education and training of doctors and nurses, but when the chips were down, their initial enthusiasm had waned.
Patients were being referred for specialist treatment abroad, however, when these patients returned to Gaza, there was no follow-up arranged and the quality of the surgery was in some cases substandard; there were many cases MiST and myself had to revise. One such patient had paid $20 000 for the management of his open tibial fracture. On his return to Gaza, we had to start the procedure again, as the external fixator applied was inadequate and applied by someone with limited knowledge of anatomy and the biomechanics of the device applied! The status quo seems suits both, the local establishment and the foreign health service providers, who receive a constant source of paid referrals from Gaza. The bill for the medical treatment in hospitals outside of Gaza is paid by the West Bank authorities. This inertia in the system seems to prevent any telling changes to the health service provision in Gaza.
Having left Gaza in January 2011, the MOH have invited me back to Gazato perform operative procedures on complex cases, and possibly to try and make some changes in their health system. My time in Gaza was fruitful in many respects. The patient and staff were grateful and of the cases MiST managed, all have improved. Moreover, I have made some good friend and colleagues in Gaza and sitting in the Madhaf restaurant or Roots café bar, one would not know you were in a siege or war zone!
However, I was now realising the gravity of the project I was ask to undertake in Gaza. The difficulties had arisen from the conflicting policies, in and outside the Gaza Strip. Some of these policies were developed over years living under a state of ‘alarm’ where Gazans were lacking a safe present and a secure future. The Gaza Strip health system both under occupation and siege has not been allowed to develop into a functional institution. There are too many players with differing agendas involved in the Gazan Health system and so progress is a difficult path to take.
The strong-minded people of Gaza just want to live a normal life. Have constant employment, quality education for their children, quality health care for their families and the ability to travel abroad on holidays. Something we take for granted in the West.
Mr S A Khan and Mrs A Drakou (Consultant Orthopaedic Surgeons, MiST Foundation, Correspondence to orthosak@hotmail.com) are guests contributors at Facilitate Global