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While the Israeli Parliament (the Knesset) Resolution on October 28, 2024, to ban UNRWA in Israel and OPT will dramatically aggravate living conditions of Palestinian refugees and non-refugee people across the Palestinian Territory occupied by Israel since 1967, it represents an intentional denial of access to functional lifesaving health services currently operating, which may have a war-crime and genocidal character in Gaza.

The war in Gaza has an outstanding character, not only because of its severity but also because of the immediate, simultaneous and massive destruction of socio-economic structures critical for survival and human security, the massive number of war injuries and deaths whilst health workers and health serviced infrastructure and services provided by various actors, including UNRWA (Al-Jadba, G. et al, Feb 2024) are being targeted Although the war in and on Gaza severely hit all non-health related aspects of life, this article highlights the inevitable consequences of the Israeli decision to ban UNWRA from operating in the occupied territory especially from a humanitarian and health perspective.

Introduction

The Palestinian Israeli Conflict/war is well in its second century. Despite being holistic and persistent in nature, it has localized and extremely violent episodic manifestations. Since the 1948, Gaza evolved into an isolated Strip, managed by Egypt, hosting refugees that are twice more than original Gazans. It was twice occupied by Israeli troops, first in 1956-1957 and 1967-to date. In 2005, Israel dismantled its settlements and withdrew its infantrymen from Gaza, maintaining aerial, maritime and close land and communication control. . Following the 2006-2007 takeover of power by Hamas, Israel declared the Gaza Strip as hostile territory which justified restrictions on movement of persons, of transfer of fuel, electricity and other supplies, converting Gaza into the world “largest open-air prison” in which around 2.4 million Palestinians, mainly refugees live. Ever since, Gaza has become a constant target of United Nations humanitarian appeals. Israel and Hamas constantly exchanged fire with open larger scale wars in 2008, 2009, and 2014. As a result, 6,407 Palestinians and 308 Israelis were killed between 2008-2023 .

The ongoing- more than year-long war in and on the Gaza Strip extended to the West Bank and swelled into a Levantine war in and around historical Palestine (Israel and the Occupied Palestinian Territory). However, the epicenter of the humanitarian disaster in the entire region is the Gaza Strip, where a unique combination of vast and deliberate destruction of all aspects of socio-economic life is taking place with around 150,000 war-trauma deaths and injuries (mostly women and children) on one hand and targeted destruction of health services and systems desperately needed to remedy this disaster and to save lives, on the other.

On the other side, sseveral major actors are coping (or are trying to cope) with the humanitarian consequences of this war and still provide essential health and other life-saving services. Prior to this war, UNRWA’s health program provides a wide spectrum of health services that includes reproductive health (ante-natal, natal- and post-natal care and family planning), infant and childcare health (including immunization, well baby clinics and growth monitoring, screening and medical checkups), school health, prevention and control of non-communicable diseases (NCD), outpatient care, oral health, specialist services and rehabilitation .
According to the Health Cluster in OPT, UNRWA still contributes to over half of the people reached with health services since 7 October 2023. Between 7 October 2023 and 20 October 2024, UNRWA provided over 6.14 million medical consultations across the Gaza Strip . These are health services desperately needed to also cope with ongoing and projected non-violent morbidities and mortalities generated by the worsening socioeconomic conditions in Gaza.

Although not providing hospital services UNRWA has more than 13,000 staff based in Gaza, of whom 3,500 are engaged in humanitarian response related activities, extended to a broader population” . With its PHC and medical points, which are staffed with more than 1000 health professionals, it is the most important provider of humanitarian health assistance, second only to the Ministry of Health (controlled by Hamas). UNRWA, already a major public primary health-care provider in Gaza both before and during the war, has also started responding to emerging needs, such as care for wounded people, by providing step-down (or intermediate) levels of care. The agency is supporting shelters near hospitals for patients who have been discharged early, thereby freeing up hospital beds (Al-Jadba, G. et al, Feb 2024).

Situation analysis:
A. War-related health consequences
I. War-related trauma death and casualties
According to MOH-Gaza, at least 43,061 Palestinians have been killed and 101,223 have been reported injured between 7 October 2023 and 29 October 2024 (Reliefweb 2024), mostly women and children. Many of wounded Palestinians (over 104,000 so far) will die in -and -outside health facilities in the days and weeks following their injuries. Physical war traumas are accompanied by mental traumas for the injured, their families and communities

War death taking place during and after medical treatment was a subject of a study carried out over a period of 10 years (2001 - 2011). It demonstrated that among 4,596 battlefield fatalities, 87.3% of all injury-related deaths occurred in the Pre-Medical Treatment Facility (PMF) setting. This means that up to 12% of all war injuries resulted in mortality either during or after medical treatment (Eastridge,2014). Because of the catastrophic conditions of health services, especially hospitals in Gaza, these in- and post-treatment trauma mortalities are likely to be much higher. The lack of search and rescue system in Gaza (lack and targeting of personnel, equipment and vehicles), the number of dead persons in the destroyed buildings and houses is unknown and is estimated to exceed 10,000 .

II. War-related non-violent death resulting from destruction of the socioeconomic determinants of health:

II. a. The socio-economic determinants of health as defined by WHO, include security, economy, sources of food and water, physical environment (housing and working places), education and culture (WHO, 2017).

A study (Geneva Declaration 2008) conducted in conflict-affected regions/countries have demonstrated that non-violent deaths substantially surpass those direct violence-related deaths. Countries in war start with peacetime crude mortality with gradual but continuing rise of additional death (excessive mortality) caused by “direct” war injuries and by “indirect” war-related diseases as a result of the deterioration of living conditions (Geneva declaration, 2008, figure 2.1, P33). In ten countries affected by conflict, the ratio of "indirect" deaths to direct conflict-related deaths was found to range from 2.3 times higher in the Darfur-Sudan conflict (2003-2005) to 15.7 times higher in the Sierra Leone conflict (1991-2002) (Table in the Annex). A comprehensive review of the situation in Gaza-Strip in the early months of the conflict reveals that “substantial investments and long-term efforts will be essential to address the extensive damage and losses incurred as a result of the ongoing conflict”. “If the 2007–2022 growth trend returns, with an average growth rate of 0.4 percent, it will take Gaza 350 years just to restore the GDP levels of 2022.” (UNCTAD 2024). This means that deaths resulting from non-trauma related death will continue as long as poor socioeconomic environment persists, even after end of war.

II. b This pattern of war-related, yet non-violent, morbidity and fatalities caused by deterioration of socioeconomic living conditions is applicable to the ongoing Gaza war, often not considered under the local and global attention on casualties, injuries and delivery of supplies. Victims are children, women and elderly, ICU patients, cancer, kidney, and other chronically ill. According to OCHA , lack of fuel restricts water provision by private providers resulting in daily consumption of water reduced to less than 6 litres for about 1.4 million Most of Gaza ‘s population have limited or no access to food and safe water and malnutrition is spreading. The situation is especially serious in the north, where 1 in 6 children under the age of 2 is acutely malnourished.

Parallel to targeting individuals, the war made Gaza, besieged since 2007, “uninhabitable” . Most residential houses, governmental and non-governmental facilities, schools, universities, religious, historical and cultural sites, fabrics, warehouses, land and places of agricultural production were destroyed. Additionally, critical infrastructures such as communication hubs and roads have been severely affected, disrupting transport and communication networks, and hindering motorized travel within the strip

There are 2000 cases of cancer/year, including 122 children, 60,000 living with diabetes, 225,000 with hypertension, 45,000 with cardiovascular and around 1000 dialysis patients in Gaza (WHO -OPT emergency October 2023). UNRWA is main provider on NCD services for refugees. There are some 60,000 pregnancies in Gaza and over 180 deliveries a day. UNRWA’s Reproductive Health program is key to early detection and management of complicated pregnancies and RH problems and anticipate and refer difficult deliveries to hospitals.

Infectious diseases including acute respiratory infections, diarrhea, hepatitis and vaccine-preventable diseases are on the rise . UNRWA -PHC clinics as part of the national disease surveillance system play a critical role in disease prevention, early warning and control of communicable diseases.

In August 2024, circulating variant poliovirus type 2 has been confirmed in Gaza in a 10-month-old paralysed child. Two rounds of polio vaccination were conducted by the Palestinian Ministry of Health in collaboration with WHO, UNICEF, UNRWA and other partners, was part of emergency efforts to stop a polio outbreak in Gaza .
“Almost all of the estimated 1.2 million children in Gaza are in need of MHPSS” (UNICEF 14/07/2024). According to ACAPS , “humanitarian responders and those affected in Gaza have reported a significant increase in MHPSS needs, including widespread depression, anxiety, and trauma ”

These non-violent mortalities “normally” occur time after war-related progressive deterioration of socio-economic and health determinants and further escalate with time. However, the destruction of Gaza’s socioeconomic and health determinants was uniquely massive, inflicted on the very onset of war in October 2023, is further ongoing (it has been estimated that 85,000 tons of bombs were used so far), and was compounded by a declared tight land, air and sea blockade, severely limiting the entry of essential supplies such as food, water, fuel as well as impeding supply distribution within the Gaza strip. Gaza became uninhabitable and 90% of its population is displaced (some several times). Thirteen months into this total war, the expected war-related nonviolent death resulting from destruction of socioeconomic environment could go as high as 9 times that of trauma-related death (simulating that of DRC and South Sudan).

UNRWA contributes to stabilizing the socio-economic health determinants through various social and economic programs (relief and social services, infrastructure and camp improvement, support services and health services. However, school education is the flagship of UNRWA in “peacetime” consuming 58% of UNRWAs annual budget . UNRWA runs 284 schools operating in 183 education premises in Gaza Strip, staffed by more than 10,500 education personnel, serving around 300,000 registered pupils. (United Nations 2024). Schools’ health is part of the national preventive health program. Gaza school children lost a substantial part of the scholastic year 2023-2024. UNRWA Schools are used by IDP for shelter and protection and sites for reception of humanitarian assistance items (food, water etc.) by UNRWA and other actors.

Because of its decades-long experience, UNRWA acted constantly between relief and transition, and is an irreplaceable actor in recovery and reconstruction in any “Day After” scenario.

B. Targeting the health system

While the work of numerous national health NGOs (including Palestine Red Crescent Society PRCS provides emergency services, manages a hospital and several clinics) and International NGOS (including ICRC) is critical, it frequently tend to be geographically localized and time limited. The weak private sector is further substantially weakened. There are two de facto permanent bodies which operated in the past decades and are currently operating across the entire Gaza Strip: the local Gaza government and UNRWA. Even considering the ongoing critical work of the numerous national and international NGOs, the UNRWA is the second major single humanitarian actor in Gaza’s humanitarian and health disaster, next only to the “Hamas-controlled MOH”.

B.I. Targeting the Ministry of Health.

Overthrowing “Hamas government” was/is a declared target of Israel, supported by the US and some Western Governments. However, besides Hamas government civil officials, the Israeli army killed and detained hundreds of government employees, many responsible to provide social services including environmental sanitation, distribution of water and food, rescuing survivals from rubble etc. Public buildings, municipalities, archives, logistics and warehouses were destroyed, destroying the ability of day-to-day governance, crucially needed to provide essential services and distribute aid. The majority of public service employees moved southward to Rafah with their families as ordered by the Israeli Army (45 evacuation orders), joining the 1,9 million displaced, which is severely affecting health care delivery.

On the onset of war, there were 159 PHC, 35 hospitals (12 governmental hospitals) in Gaza in which 11,128 health staff used to work, including 2,143 physicians, dentists, and pharmacists, 1,433 paramedics, 3,071 nurses, 343 midwives and 3,377 administrators (MOH 2021). In 2021, the MOH hospitals conducted 66,592 operations, registered 36,287 live births, and carried out 9,219 caesarian sections. There were 1,013 patients regularly receiving kidney dialysis. By February 2024, most hospitals and PHCs were bombed or rendered nonfunctional. 374 health workers have already been killed, some in targeted assassinations . Many were detained. Because of direct targeting hospitals and because of siege, lack of fuel, medical supplies and equipment, and because huge numbers of IDPs searching for shelter and protection around and inside still-functioning hospitals, most hospitals lost relevant abilities to continuously deliver tertiary and substantial parts of their secondary services, including advanced cancer treatment services and complicated operations.

B. II. Targeting UNRWA:

Recently, Israel called for UNRWA closure/replacement beginning January , later accusing twelve of its employees of terroristic involvement. By end January 2024, fifteen Western UNRWA donors, led by the US and the UK suspended funding , though most of them reinstated it later, with exception of the US (the main donor). Israel Knesset resolution of 28 October 2024 crowns complement accusations and atrocities against UNRWA in Gaza.
Since beginning of war in October 2023, 273 UNRWA team members were killed, 190 UNRWA installations damaged through 464 “incidents” . Twenty out of 27 UNRWA PHC were destroyed or rendered nonfunctional. Currently, UNRWA operates through 3 UNRWA Health centres, 4 temporary health centres and 52 medical points in and around IDP shelters across Gaza.
The incoming US administration may totally stop funding UNRWA, as it did in 2018 which will further aggravate Gaza´s humanitarian disaster (and Palestinian refugees in entire region).

Conclusions
UNRWA health and social services in Gaza directly contribute to reducing war related trauma mortality by supporting overburdened hospitals and emergency services. UNRWA health and social programs are major contributor to Gaza`s socioeconomic determinant of health, which reduces the far higher mortality of non-violent health conditions caused by the extreme deterioration of socio-economic health determinants. UNRWA presence and work (services, staffing and logistic network) is the “backbone of all humanitarian response in Gaza ”. Israel’s ban of UNRWA will not only end its presence and operations but will irreversibly damage the entire humanitarian relief system in Gaza. This equals a Gaza-wide denial of access to life saving assistance, which will inevitably cause a major surge of avoidable deaths for a long time. Israel’s intention to replace UNRWA by “private security companies” is practically doubtful and scientifically absurd, since it derides the entire national health system of Gaza into a mere drug distribution network.
Humanitarian access, mandated by UN General Assembly resolution 46/182, refers to a twopronged concept, comprising humanitarian actors’ ability to reach populations in need and affected populations’ access to assistance and services .

The denial of access to humanitarian lifesaving assistance to populations may represent a war crime or an act of genocide (Rottensteiner 1999). Israel’s blockage and planned /termination of UNRWA work in OPT is not a onetime denial of access for refugees (70% of Gaza’s population) to life-saving services, but the permanent elimination of a major provider of lifesaving humanitarian assistance for most of Gaza’s population.
References
1. Al-Jadba, G. et al (Feb 2024): UNRWA at the front lines: managing health care in Gaza during catastrophe. Lancet, Published Online February 13, 2024, https://doi.org/10.1016/S0140-6736(24)00230-7
2. Eastridge, B. J. et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J. Trauma Acute Care Surg. 73, S431-437, (2012) DOI :10.1097/TA.0b013e3182755dcc
3. Geneva Declaration (2008). The Global Burden of Armed Violence, figure 2.3 P40 <https://www.unodc.org/documents/data-and-analysis/Crime-statistics/Global-Burden-of-Armed-Violence-full-report.pdf
4. ICJ (International Court of Justice): Application of the Convention on the Prevention and Punishment of the Crime of Genocide in the Gaza Strip (South Africa v. Israel). At:
https://www.icj-cij.org/sites/default/files/case-related/192/192-20241008-int-01-00-en.pdf
5. MOH-State of Palestine: Health Annual Report 2021. P33 At: ttps://site.moh.ps/Content/Books/Hqgu4D5vfT6bDhDUtl36GHhx9oYlCS9JplXYDfOMKrnDt6YoDPkPdl_I6mhnD3xb5MaPpX1mx6k6J4WowTnGUc1135KRHMmuMwEi1Zh1QUmFY.pdf
6. Reliefweb (20 October 2024): UNRWA Situation Report #144 on the situation in the Gaza Strip and the West Bank, including East Jerusalem. At: https://reliefweb.int/report/occupied-palestinian-territory/unrwa-situation-report-144-situation-gaza-strip-and-west-bank-including-east-jerusalem-all-information-14-16-october-2024-valid-16-october-2024-2230-local-time
7. Rottensteiner, C.: The denial of humanitarian assistance as a crime under international law. IRRCSEPTEMBER 1999 VOL.81 N°835. At:
https://internationalreview.icrc.org/sites/default/files/S1560775500059794a.pdf
8. Schwendimann, F.: The legal framework of humanitarian access in armed conflict, International Revei of the Red Cross. Volume 93 Number 884 December 2011. At: https://www.corteidh.or.cr/tablas/r29536.pdf
9. UNCTAD. Gaza: Unprecedented destruction will take tens of billions of dollars and decades to reverse, At: https://unctad.org/news/gaza-unprecedented-destruction-will-take-tens-billions-dollars-and-decades-reverse (2024).
10. United Nations (November 2024): How has the war in Gaza affected UNRWA’s ability to support Palestinians? At: https://news.un.org/en/story/2024/11/1156606#:~:text=The%20UNRWA%20education%20programme%20in%20Gaza%20was%20the,10%2C500%20education%20personnel%2C%20serving%20around%20300%2C000%20registered%20students.
11. WHO (2017): Determinants of health. At: https://www.who.int/news-room/questions-and-answers/item/determinants-of-health
Annex 1:
Direct vs. indirect deaths in several recent armed conflicts.
The Geneva Declaration (2008): Global Burden of Armed Violence, Page 40. At: https://www.unodc.org/documents/data-and-analysis/Crime-statistics/Global-Burden-of-Armed-Violence-full-report.pdf