Gaza’s Human Crisis Demands a Rethink

A Cataclysm Is Born

Hamas’s October 7, 2023, massacre of 1,200 Israelis, sexual violence, and seizure of around 240 hostages shocked Israel politically and psychologically. At the same time, Hamas cynically plunged its own Palestinian population into infinite peril. Soon, over a quarter of a million Israelis were displaced from around Gaza and the Lebanon border. Israel’s ferocious response to the Hamas attacks, now entering its fourth month, turned into a sustained aerial and ground campaign, accompanied by a brutal siege that continues to severely limit fuel, electricity, water, food, and medicine to Gazans.

Both sides see the war in existential terms and demonstrate little regard for civilian lives. Israel, thus far only modestly successful in its fight to destroy Hamas’ vast underground structures, has laid waste to much of what is aboveground. The war—including its vast human toll—has in turn spurred a volatile geopolitical crisis that, as recent events in Lebanon, Iraq, Iran, and the Bab al-Mandab Strait have suggested, may spark a wider regional conflagration.

Israel’s assaults have damaged or destroyed 70 percent of Gaza’s housing and nearly half of its infrastructure, and according to the Gaza Ministry of Health, killed more than 23,000 people—more than two-thirds of them women and children—and injured another 59,000. That accounts for more than 3.5 percent of Gaza’s 2.3 million citizens. Almost two million people have been displaced to areas that remain acutely unsafe. They remain unprotected from the elements and face severe shortages of potable water, fuel, and food. The result is a human catastrophe that threatens to generate deaths and impairment that exceed the extreme harm caused by bombardment. In the meantime, Israeli leadership has denied responsibility while Hamas leadership remains underground and out of sight, or overseas, unaccountable for what it has provoked through its atrocities. Thus far, international pressure has largely failed to change the conduct of the war. A much tougher, more aggressive U.S. leadership is now urgently needed to press for changes by Israel and Hamas and mobilize others around a common strategy, if Gaza’s population is to stabilize, see some early signs of hope of recovery, and escape the apocalyptic situation they now inhabit.

Healthcare Erased

On January 3, the United Nations reported more than 400,000 cases of infectious disease since October 7, including 180,000 cases of upper respiratory infections, along with increases in meningitis, skin rashes, scabies, lice, and chicken pox. As of December 21, the World Health Organization (WHO) reported more than 100,000 cases of diarrhea, half among children under five, a 25-fold increase since the war began. More than 90 percent of families are experiencing crisis levels of hunger and malnutrition that significantly lower resistance to further disease. The World Food Program’s chief economist claims that more than 80 percent of the people in the world suffering famine and catastrophic levels of hunger reside in Gaza.

Gaza’s entire health system has been decimated, with only a third of hospitals even partially functioning. As of December 29, the WHO reported 294 attacks on healthcare—including hospitals, clinics, ambulances, health workers, and patients since October 7—that have killed 600 people, including patients within hospitals. Not since the incendiary and high explosive bombing seen in the Korean War 70 years ago has such a high percentage of hospitals in a war zone been so severely damaged or destroyed. 

Those hospitals still open remain severely overcrowded, without the means to provide baseline support to patients. Dr. Richard Peeperkorn, the WHO emergency director for the Gaza, said that in many hospitals, parents of very sick children are now instructed to remove them from hospitals and care for them by whatever means at home. Specialty services such as cancer centers, including those for children, have been shuttered. There are no care options to address Gaza’s severe mental health needs, given the closure of the only psychiatric hospital and all six community mental health centers, as well as the collapse of teletherapy due to blackouts in internet and telecommunications.

No One to the Rescue

UN agencies, the International Committee of the Red Cross, and a small number of international NGOs, most notably Médecins Sans Frontières (MSF)/Doctors without Borders, struggle to transcend operational barriers and worsening insecurity. Supply blockades, road and infrastructure damage, and attacks on health care facilities and professionals have utterly stymied health and humanitarian workers in carrying out their mission. They are able to provide at best a minor fraction of what they are capable of delivering and what is urgently needed—at great risk. UNRWA, the UN Relief and Works Agency for Palestinian Refugees in the Near East, the main provider of health and education in Gaza, has lost over 146 staff members as of January 10, the highest loss of staff ever by a UN agency in a conflict. 

Quite conspicuous and disturbing is the indifference of Israeli forces to the severely wounded and sick patients they encounter in hospital assaults. International humanitarian law obligates combatants to respect and protect patients, including ensuring care for them, as well as to minimize harm to civilians in military operations. These duties apply even if a hospital is used by Hamas for tunnel access or other military purposes. 

Israeli forces have taken almost no steps to minimize harm to patients during hospital sieges and assaults, by, for example, providing essential medical supplies, medication, sufficient fuel for sustained electricity, and food. A month after the Israel Defense Forces (IDF) assaulted al-Shifa Hospital, a joint UN mission led by the WHO found that the hospital, while still trying to care for desperately wounded and ill patients, lacked fuel, oxygen, blood for transfusion, staff, food, safe water, and supplies. The team saw patients with traumatic injuries being sutured on the floor, with little to no pain medication.

The IDF has exacerbated the harm by detaining, interrogating, and abusing members of medical staffs. As of December 14, it had detained at least 41 health workers (and another 45 in the West Bank). Palestinian Red Crescent Society medics were even detained while participating in WHO supply and evacuation convoys. Some, detained in mid-November, were still held a month later. A medic who was released told WHO colleagues that he had been beaten, stripped, blindfolded, subjected to degrading and humiliating abuse, and “left to walk towards the south with his hands still tied behind his back, and without clothes or shoes.” 

In many cases, the IDF impeded safe evacuation of seriously ill or wounded patients, even as it demanded that they leave hospitals. Israeli troops shot at WHO convoys seeking to resupply hospitals. Two people were killed, likely by the IDF, in clearly marked MSF cars, and on multiple occasions MSF ambulances were destroyed.

The UN Security Council has been largely impotent in addressing the Gaza crisis, in large part because the United States has used its veto power to block otherwise broadly supported resolutions that would have pressed for a ceasefire. (The December 22 Security Council resolution on Gaza, which the United States abstained from voting on, contained no reference to a ceasefire.) The Biden administration has repeatedly called on Israel to protect civilians in the conduct of the war, including a direct call by President Biden to end indiscriminate bombing of civilians. Nonetheless, Israel has refused to change its battlefield tactics significantly even as Israel fails to achieve its strategic goal not just of defeating Hamas but eliminating it, while winning release of the remaining hostages. The Biden administration’s only major success to date, supported by U.S. allies, has been to successfully press for a one-week pause in late November that led to modest temporary increases in humanitarian aid and the release of 100 hostages. 

When the pause ended on December 1, Israel renewed its massive assaults, including in the south, where it instructed Gazans to flee. The Netanyahu government has also rejected proposals for a reformed Palestinian Authority to play a significant role in the governance of Gaza, while doing little if anything to curb settler violence in the West Bank and moving forward with annexation there. Far-right ministers continue to call for expelling Palestinians from Gaza. Although Israel opened a new access point for humanitarian aid at Kerem Shalom, the gains thus far in humanitarian flows have been inconsequential. International organizations have faced continuing challenges delivering aid, particularly in the north, where the United Nations says only a quarter of planned aid missions were successful from January 1 to 11, compared to a 70 percent success rate in December.

 The Gazan Trap

The stark reality is that in 2024 Gazans are likely to be forced to live for an indefinite period trapped in conditions of unspeakable suffering, without anything approaching minimal housing, nutrition, health services, mental health support, water, a functioning economy of any description, and hope. A higher and higher percentage of Gaza’s population is likely to experience premature death, extreme injury, and life-threatening illness. Gaza is steadily becoming the site of thousands of tents occupied by a sick, grieving, and burgeoning population, where the death toll from preventable and treatable disease increasingly competes with that from bombardment. 

At present, there is no visible pathway out for Gazans to avoid becoming ruined for a generation or more. This scenario is entirely plausible, given the continuation of the Israeli war effort, compounded by no apparent change in Hamas’s calculations, continued confusion and uncertainty over what governing arrangements might eventually be possible in postwar Gaza, the ever-present threat of regional escalation, and the continued inability of UN agencies and other international groups to operate inside Gaza.

What to Do Right Now?

The United States is the only country that can exercise significant leverage over Israeli conduct in the war, but thus far it has not used that influence effectively, while respecting Israel’s legitimate security interests. In the meantime, the United States has stimulated intense anger and resentment among its allies, while its reputation has been seriously damaged, as credible organizations now accuse the administration of complicity in war crimes. A case alleging Israeli genocide against Palestinians is pending in the International Court of Justice.

It makes no sense for the Biden administration to continue hoping that persuasion alone will be sufficient to restrain Israel’s military tactics and increase aid access and delivery. That approach has failed with few exceptions. Israel has announced plans to reduce the number of IDF troops in Gaza next month, but intense assaults continue in the meantime. Likewise, it makes no sense to simply look beyond the burgeoning catastrophe and focus entirely on “the day after” the war ends.

As 2024 opens, the Biden administration urgently needs to reset its strategy, focused on what needs to be accomplished now, to avoid the unthinkable outcomes that look entirely possible.

Beginning right away in the first quarter of 2024, the Biden administration should make clear that it is now a high U.S. policy priority to stabilize and protect the Gazan population and begin a process of recovery. That should include a statement that there will be no further U.S. military assistance until there is concrete proof that Israel is no longer imposing significant harm upon civilians in military operations, fully restores electricity and water, and actively expedites a major expansion of critical assistance, including crash efforts to stem the food crisis. To achieve these ends, the United States should also indicate that it is also prepared to forego the use of a veto in the UN Security Council to block a ceasefire resolution. The following steps, which do not impede Israel’s security, should be implemented rapidly:

  1. Require concrete proof that the IDF is beginning to comply with international humanitarian law on protecting civilians and health care and implementing well-recognized “deconfliction” mechanisms to facilitate safe medical and humanitarian passage and access to care.
  1. Quadruple the flow of food, fuel, medicines, and construction materials, while restoring electricity and water and speeding up inspections of goods and vehicles. In this period, the United States should refine what are accurate, truly sufficient targets for humanitarian aid flows over the long-term and establish mechanisms for tracking whether they are met.
  1. Lead the establishment of an ad hoc coalition of Palestinians, UN agencies, international NGOs, and committed states to support an accelerated stabilization of Gaza and first phase of recovery. The WHO, UNRWA, the World Food Program, and UNICEF will play essential roles in restoring basic health and nutrition.
  1. Expand U.S. technical support through the Centers for Disease Control and Prevention and U.S. Agency for International Development to WHO and other UN agencies to strengthen Palestine laboratory capabilities, infectious disease data surveillance and monitoring, supply chains, and delivery of health services.
  1. Engage Arab countries to press Hamas for a cessation of fighting, respect of the integrity and autonomy of humanitarian aid planning and distribution, an end to the use of civilians as shields, and the expedited release of hostages.

Courage to Face Reality

There has recently been much intense discussion on how to end the violence, establish effective governance free of Hamas in the near and longer term, and move toward a two-state solution, which is increasingly recognized as the only plausible way to end the larger Israeli-Palestinian conflict (even as the Netanyahu government rules out that option). That debate should and will no doubt continue. But in the meantime, the cataclysm for Palestinians in Gaza is no longer on the horizon. It is here and now, in front of all to see. The United States needs to recognize the global threat of Gaza becoming a permanent wasteland of suffering, become far tougher and more assertive toward Israel and Hamas, and initiate the urgent steps needed to stabilize the Gazan population and restore some early hope that an eventual recovery is within reach. A wasteland outcome will damage U.S. national interests and, arguably, Israeli interests as well, if it results in unfathomable suffering that defies any ethical explanation, sparks higher regional instability, and creates a long-term barrier to a political resolution. The proposed U.S. strategy is certainly not guaranteed of success and carries risks, yet the alternative—the current status quo—is far worse. In essence, the approach is a call for boldness, courage, humility, sustained commitment, and intensified engagement.

Leonard Rubenstein is a senior associate with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C. He is also distinguished professor of the practice at the Johns Hopkins Bloomberg School of Public Health, and author of Perilous Medicine: The Struggle to Protect Health Care from the Violence of War (Columbia University Press, 2021). J. Stephen Morrison is senior vice president and director of the Global Health Policy Center at CSIS.

The authors wish to offer special thanks to Michaela Simoneau and Sophia Hirshfield, associate fellow and research associate, respectively, at the CSIS Global Health Policy Center, for their extensive support in the production of the commentary.