Intended for healthcare professionals

Analysis And Comment

Hope and despair over health in Gaza

BMJ 2006; 333 doi: (Published 19 October 2006) Cite this as: BMJ 2006;333:845
  1. Allan G Hill (ahill{at}, Andelot professor of demography1,
  2. Cari Jo Clark, research coordinator2,
  3. Ismail Lubbad, research coordinator, Gaza2,
  4. Claude Bruderlein, director2
  1. 1 Harvard Center for Population and Development Studies, 9 Bow Street, Cambridge MA 02138, USA,
  2. 2 Harvard Program on Humanitarian Policy and Conflict Research, Cambridge MA
  1. Correspondence to: A G Hill

    The Israeli re-invasion of Gaza this July has redrawn the world's attention to the dire straits of the population living in the Gaza Strip. There, within an area the size of the Isle of Wight, 1.4 million people live without free access to the outside world. Contrary to international hopes, the Israeli decision to withdraw from Gaza in September 2005 has led to increasingly tight control over the movement of goods and people. The destruction of the Gaza power station in addition to the damage to bridges, roads, and other infrastructure can only worsen the plight of Gazans in the coming months.

    Untenable dependence on aid

    But the current crisis has been looming since well before the renewed hostilities this July. Despite the massive investment by Western donors in public infrastructure over the past decade, the Gaza Strip was never designed to sustain a viable and developed society. For the past 50 years it has hosted the largest concentration of refugees in the world, maintained in a state of dependency on international assistance at the highest levels per head since the second world war. The Oslo peace process was launched to tackle this structural dependency, hoping to transform Gaza into a self sustaining and open economy based on links to the West Bank and beyond.

    Gaza is the first region in the Occupied Palestinian Territory to experience the effect of Oslo's demise in the form of major threats to health and human security. Its population will double in the next 22 years.1 Water resources are on the verge of exhaustion; residential overcrowding is severe, with several generations living in the same house; schools are running on two to three shifts; and unemployment and poverty have both doubled in the past five years. In 2004, 36% of men and 33% of women were unemployed or underemployed in Gaza; daily wage rates were less than half those in Israel and the settlements; and 27% of school aged children were at work rather than attending school. For the last quarter of 2005, the monthly income of 63% of households fell below the poverty line and 43% were living in deep poverty.2

    Aid dependency is extreme.3 Before the recent cuts, the value of government assistance per household had risen to $188 (£100; €148), with an additional $42 provided by the United Nations Relief and Works Agency and $125 by political parties. The boycott of the Hamas government has led to most of this aid being blocked.

    Surprisingly, some key health indicators are good. Infant mortality is close to 30/1000, almost all children are fully vaccinated, and the proportion of professionally assisted deliveries is high. But the limits of these technology based interventions in isolation are becoming clear. We see a disturbing pattern of excess death rates, especially for young men. Non-communicable diseases and cancer are growing in importance.1 Prevention requires interventions to change behaviour (such as diet and smoking control). Such change is not readily accomplished without strong government control, which seems increasingly remote.

    Where next?

    One reason for the current situation is the international community's focus on the palliative effect of aid rather than promotion of human security and human development concerns. It is time to move beyond the narrow technical and medical approaches to health and for the region to exert independent control over its health issues. One way ahead is to adopt a population based approach that concentrates on equity and the social, political, and economic determinants of health. For years, the world has been impressed by the remarkable outcomes of public health and education programmes in the Palestinian refugee community. Yet, these outcomes are not sustainable and cannot subvert the requirements for a stable and open society, such as equity of access to quality services, planning for development, productive employment, free movement of people and goods, and democratic governance.


    • Competing interests None declared.


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