Healthcare under siege: Geopolitics of medical service provision in the Gaza Strip

Social Science & Medicine xxx (2015) 1e9

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Healthcare under siege: Geopolitics of medical service provision in the Gaza Strip Ron J. Smith* Department of International Relations, Bucknell University, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 24 January 2015 Received in revised form 7 October 2015 Accepted 8 October 2015 Available online xxx

Siege, a process of political domination aimed at isolating an entire population, represents a unique threat to healthcare provision. This study is a qualitative examination of the impacts of siege on the practices and systems that underlie health in Gaza. Data are from participant observation conducted over a period of six years (2009e2014), along over 20 interviews with doctors and health administrators in the Non-Governmental Organisation (NGO), Governmental, and United Nations sectors. Analyses were informed by two connected theories. First, the theory of surplus population was used, an idea that builds on Marx's conception of primitive accumulation and Harvey's accumulation by dispossession. Second, Roy's theory of de-development was used, particularly as it is connected to neoliberal trends in healthcare systems organizing and financing. Findings indicate that siege impinges on effective healthcare provision through two central, intertwined processes: withholding materials and resources and undermining healthcare at a systems level. These strains pose considerable threats to healthcare, particularly within the Ministry of Health but also within and among other entities in Gaza that deliver care. The strategies of de-development described by participants reflect the ways the population that is codified as a surplus population. Gazan society is continually divested of any of the underpinnings necessary for a well-functioning sovereign health care infrastructure. Instead of a self-governing, independent system, this analysis of health care structures in Gaza reveals a system that is continually at risk of being comprised entirely of captive consumers who are entirely dependent on Israel, international bodies, and the aid industry for goods and services. This study points to the importance of foregrounding the geopolitical context for analysis of medical service delivery within conflict settings. Findings also highlight the importance of advocating for sovereignty and self-determination as related to health systems. © 2015 Elsevier Ltd. All rights reserved.

Keywords: Gaza Health Siege Geopolitics NGO Neoliberalism

1. Introduction The effects of conflict on healthcare, particularly on public efforts to protect and promote health, are well-established (Barghouthi and Giacaman, 1990; Farmer, 2004; Ityavyar and Ogba, 1989; Sidel and Levy, 2008; Ugalde et al., 2000). Siege represents a specific expression of conflict around territoriality between and among nations. It is a process of political domination aimed at isolating an entire population as a means of imposing collective punishment on ordinary people to demand political changes from their governments (Geldenhuys, 1990; Gordon, 1999). In 2006, Israel imposed a comprehensive unilateral siege

* Bucknell University, 342 Academic West, Lewisburg, 17837, PA, USA. E-mail address: [email protected].

upon Gaza, which was then supported by actions taken by Egypt, the European Union and the United States, through anti-terrorism provisions. The isolation that siege generates is particularly important within the globalized context of health and development (Graham, 1998; Sparke, 2006); in this context, issues of geo-political control and dependency versus autonomy become especially salient. Indeed, the phenomenon of siege makes clear the importance of understanding the relationships between power, social relations, and health (Flores et al., 2009), along with the need for true soverignty as a critical strategy of health promotion (Becker, Al Ju'beh, & Watt, 2009; Giacaman et al., 2009). Health care provision under siege requires particularly nuanced approaches. These approaches should balance the immediate and long term needs with concerns about rights, independence, and collaborative efforts that foreground global arrangements of power (Maina-Ahlberg et al., 1997).

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Please cite this article in press as: Smith, R.J., Healthcare under siege: Geopolitics of medical service provision in the Gaza Strip, Social Science & Medicine (2015), http://dx.doi.org/10.1016/j.socscimed.2015.10.018

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With this framework in mind, this article uses a lens of critical political geography to explore healthcare provision within the conditions of siege in Gaza, particularly attending to the complex power relations inherent in this locale. The data presented here was gathered from over 20 interviews I conducted with doctors and health administrators in the NonGovernmental Organisation (NGO), Governmental, and United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) sectors in Gaza in 2014 (in the days and weeks prior to the attacks during the Summer of 2014 and with additional follow up in January of 2015) and participant observation I performed during several months of field work over a period of 6 years from 2009 to 2015. Based on critical analyses, I argue that the data collected indicates that siege impinges on effective healthcare provision through two central, intertwined processes: withholding materials and resources and undermining healthcare at a systems level. Each of these processes reflect how the strains on health care in Gaza, within the Ministry of Health and the many other entities in Gaza that deliver care, disrupts what the World Health Organization (WHO) considers the six system building blocks of a positive health care framework: Leadership and Governance, Health Care Financing, Health Care Workforce, Medical Products and Technologies, Information and Research, and Service Delivery (World Health Organization, 2007). I interpreted data using two connected theories. First, analyses are informed by Marx's notion of surplus population (Marx, 1959), an idea that builds on his conception of primitive accumulation and one that has been deepened by several scholars (Di Muzio, 2007; Harvey, 2003; Luxemburg, 1951; Vasudevan et al., 2008) and is further enriched by Harvey's notion of accumulation by dispossession (Harvey, 2003). Second, analyses are informed by the notion of de-development (Roy, 1995), particularly as this process is connected to neoliberal trends in healthcare systems organizing and financing. Prior to introducing the results, I present these two theoretical frameworks. This section describing the theoretical framing is followed by an explanation of the methodology. Then, I present the results, which hinge on two central dynamics that siege creates regarding healthcare: withholding materials and resources and undermining healthcare at a systems level. Results conclude with a section that focuses specifically on how these two dynamics, as well as other political and historical processes, contribute to the particular ways that the Gazan Ministry of Health is in a crisis situation. After putting the findings into a deeper conversation with the theories that underpin this research, I conclude with recommendations for strategies that might enable effective collaboration across the development divide around healthcare provision in this complex geo-political terrain. 1.1. Primitive accumulation, accumulation by dispossession, and surplus population Siege is a practice that invokes Marx's conception of primitive accumulation (Di Muzio, 2007; Harvey, 2003; Vasudevan et al., 2008), or more directly, Harvey's notion of accumulation by dispossession (Harvey, 2003), which describes a process wherein populations are displaced and dispossessed of their lands and livelihoods by economic elites for the purpose of financial gain. In early capitalist Europe, primitive accumulation was driven by the phenomenon of enclosure that privatized land held in common (Marx, 1959). This resulted in the displacement of populations who lived off of or supplemented their incomes through the harvest of these lands. In time, these populations were forced to leave their homes and join the surplus population, seeking jobs in the nascent capitalist enterprises. The lands themselves were expropriated for use by the wealthy classes. Marx also details this phenomenon as a

central motivating factor for colonialism, wherein indigenous populations were made surplus. Surplus population, according to Marx, refers to a phenomenon that he charges is an inevitable outcome of capitalist accumulation, or concentration of wealth, through the displacement brought about by primitive accumulation. Marx's conception of surplus population is a rejection of Thomas Malthus's argument that surplus populations are an inevitable consequence of natural population growth e Marx considered the reformation of a population as surplus as an entirely artificial process, an effect of capitalism not nature. Marx (1959:631,2) argues that capitalism creates surplus populations that he refers to as the industrial reserve army. These surplus populations represent potential laborers with a tendency to produce a downward pressure on wages, while simultaneously providing a market for manufactured goods, but always marginalized and never fully incorporated into the capitalist structure. Rosa Luxemburg expanded upon the notion of surplus populations in the context of colonialist expansion by detailing the importance of captive, non-capitalist strata to the success of capitalist regimes in her notion of internal and external markets. She posited that the external market “is the non-capitalist social environment which absorbs the products of capitalism and supplies producer goods and labor power for capitalist production (Luxemburg, 1951).” Luxemburg's reading here expands on Marx's analysis of colonialism, and explains what occurs after the initial exploitation and expropriation of indigenous territories through colonialism. Gaza, as an occupied territory, represents this external labor market to the Israeli economy. The idea of expelling Palestinian workers from the Israeli labor market is not new, rather this dynamic has long been fundamental to the Israeli notion of Avodat Ivrit (Shafir, 1989), or “Hebrew Labor,” wherein proponents of a Jewish state have advocated for the elimination of indigenous, nonJewish labor. The case of Gaza requires a variation of the concept of surplus populations. As indicated in UN documents, Gazans, particularly after the establishment of the siege, are no longer laborers in the Israeli market, but remain a captive population, forced to consume Israeli goods. The siege in Gaza represents a quite dramatic type of enclosure, via no-go zones unilaterally imposed by the Israeli government that make vast swaths of arable land off-limits (UN OCHA OPT, 2010). The surplus categorization is represented in official Israeli correspondence, as they relegated the population itself to the title of hostile entity (Israel MFA, 2007) as a result of the ascension of the political organization Islamic Resistance Movement (HAMAS, an acronym from the Arabic for the “Organization of Islamic Resistance,” hereafter referred to simply by HAMAS) to power in 2006. Analyses of my data indicated that for the Israeli siege on Gaza the conquest of raw materials is not the primary focus. Rather, the population represents a captive market, banned from productive activity on its own terms, a process that furthers dependency and hinders sovereignty. While Gaza provides no labor power to the Israeli market, its existence as an external consumer is a boon to the Israeli economy, and offsets some portion of the costs of the occupation (Hever, 2009). In effect, the siege is designed to break the duality of the role of members of the surplus population: laborers and consumers, in the interest of using Gazans solely as consumers. Political economic analysis suggests that this notion is problematic in a conventional, non-crisis framework, as a population can only be exploited to a certain point as consumers until they no longer have the capital necessary to purchase goods and provide a market for the dominant economy. Gazans are thus categorized as unnecessary as workers for the daily economic functioning of the occupying power, the Israeli state (Tyner, 2013). This categorization facilitates the deliberate process

Please cite this article in press as: Smith, R.J., Healthcare under siege: Geopolitics of medical service provision in the Gaza Strip, Social Science & Medicine (2015), http://dx.doi.org/10.1016/j.socscimed.2015.10.018

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of undermining Gazan sovereignty, what Roy (1995) terms “dedevelopment”. In this context that humanitarian aid and the politics of development become essential to the political economy of siege.

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power of governments to manage the health of their populations is increasingly undermined, coordination is often compromised, contributing to inefficiency and corruption (Giacaman et al., 2003; Menkhaus, 2010; Salvage, 2007; Simunovic, 2007; Ugalde et al., 2000).

1.2. The politics of development under siege: de-development and neoliberalism

2. Methods

As Roy (1995) points out, Gaza is a special case, in that development is not distorted in Gaza, rather any independent development is prevented, and in many ways, reversed. Roy (1995) terms this process de-development: “the deliberate, systematic deconstruction of an indigenous economy by a dominant power” (p. 4). The deliberate de-development of Gaza's economy began with the 1967 Israeli occupation of the territory and intensified with the siege in 2007 (Roy, 1995). While numerous proposals have been made regarding the development of “smart sanctions” designed to protect civilian populations (Craven, 2002; Fitzgerald, 2002; Lektzian, 2003), there is no enforceable global standard for the protection of the public health sector within contexts of siege. As part of the overall practice of siege, sanctions have catastrophic, measurable impacts on the public health of the targeted populations (Garfield, 2000; Garfield, 2001; Garfield et al., 1995; Gibbons and Garfield, 1999; Petchesky, 2000). In this way, sanctions represent a strategy of de-development of the Palestinian health sector e not the distortion of health care provision, but the elimination of the possibility of an independent health sector. In line with this theoretical framework, health care providers I interviewed readily articulated the lack of access to materials (raw materials to support infrastructure and medical supplies), which significantly undermines efforts at care. They also lamented their inability to travel, to correspond in person with their colleagues outside the strip, and to receive external training. Yet, their analyses made clear that these limitations are signifiers of a much more insidious problem regarding de-development: the intentional and continual weakening of any comprehensive, coordinated, and sovereign system of care. Indeed, the frameworks of surplus populations and accumulation by dispossession, along with the notion of de-development make particularly clear the ways that conflict (and particularly, as I argue here, the process of siege) not only create immediate shortages of supplies, but in a larger sense, operate to weaken healthcare provision through constraining indigenous economies. This constraint of indigenous economies largely rests on neoliberalism, a macro-economic process that critics argue serves to wrest control from local authorities, putting it instead into the hands of the private sector, creating “governance voids (Cliffe and Luckham, 2000).” Global conflict often paves the way for what Klein (2007) terms “disaster capitalism,” wherein the public sector becomes increasingly destabilized and the private sector rises to importance (Hamid and Everett, 2007). This is often characterized by the movement of outside “expert” actors into local spheres, including of healthcare (Cliffe and Luckham, 2000; Pedersen, 2002). In Gaza, this neoliberal process, advanced by the siege, directly affects healthcare provision and greatly aids in the process of de-development described above. Indeed, Palestinian health scholars charge that the neoliberal process in Palestine, combined with the politics of conflict and international aid constantly undermines the public health systems, and replaces them with private, NGO, and United Nations (UN) structures that are beholden to the dictates of foreign donors, and thus foreign capital (Giacaman et al., 2003; Giacaman et al., 2009; Hamdan et al., 2003). The siege of Gaza, by design, dismantles structures of public service provision as a means of punishing the population for its support of a “terrorist entity,” HAMAS. In Palestine as well as elsewhere, as the

Conducting field research in Gaza is extraordinarily complicated for an outsider. The limitations on field research are many, and include restrictions imposed by both the Israeli government and the local Gazan authority. Mindful of these challenges, the data for the analyses presented here was gathered from multiple periods of participant observation over an extended timeframe (6 years). I conducted in-depth interviews through UNRWA, the Ministry of Health (MoH), personal contacts through previous visits, and through contacts living in Gaza, a form of snowball sampling (Fontana and Frey, 2008). While conducting the interviews, the author was not a representative or employee of UNRWA, but a guest for whom UNRWA had arranged travel permits and arranged interviews with UNRWA staff at clinics and the Gaza City headquarters. Ethical approval for this research was obtained from the author's institution internal review board, and involved open-ended, semi-structured interviews. A list of broad questions was used, including what participants regarded as the major effects of the siege on healthcare and the strategies of enduring these effects in order to continue to deliver care. All participants were given paper consent forms to sign, both in English and in Arabic, approved by the Institutional Review Board at my institution, and given opportunity to discuss the nature of the research and to ask questions to clarify what precisely they were consenting to. Participants were given the options to appear in video, solely on audio recording, or in text based notes. Interviews were recorded when participants offered their consent, otherwise, the author collected field notes from the interviews. Participants were asked if they consented to the use of their identifiable data for dissemination of research, and those identified below consented to this use. I conducted the majority of interviews used in this paper with employees of the UN Relief Works Agency Health Department in the Gaza Strip. Interviews were video recorded, and I later transcribed those videotaped interviews. Due in part to concerns over privacy inherent in this research location, I did not collect demographic information about my participants, but all were adults ranging in age from approximately 35-65 years of age. I strove to achieve a balance in my participant pool in terms of geographic location, gender, rank, roles, and positions within the healthcare sector. With this balance in mind, I worked with my primary contacts at UNRWA, who arranged interviews working to assure that I was able to speak with an array of doctors, nurses, social workers, and managers throughout the system of clinics that UNRWA maintains across the Gaza Strip. My contacts at UNRWA also arranged interviews for me with managers and doctors both at the Ministry of Health and at Private and NGO hospitals. Data also consist of participant observation I conducted in Gaza over 6 years of travel to the Strip, from years 2009e2014 and the field notes associated with this process, which I recorded regularly during my time in the field both electronically and in notebooks via pen and paper. Data were analyzed using directed content analysis, as the theoretical and practical frameworks described above informed analyses (Hsieh and Shannon, 2005). Nonetheless, the analysis process relied on a process of constant comparison and data triangulation that allowed the author to refine the analyses and to deepen the theoretical framing as findings emerged (Pope and

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Mays, 1995). Rigor was further enhanced through memberchecking done through a series of follow up interviews with key participants (Krefting, 1991). The results below include illustrative quotes from a few key participants. It should be understood, though, that the analysis process included the investigation of data from my field work and the pool of interview data that included data from upwards of 20 interviews.

function because we don't have spare parts. And this problem of the spare parts is because Israel does not consider these spare parts as medical or humanitarian [supplies]. So they delay the supply of these spare parts for the equipment. Now in the ministry of health we have more than 80 [pieces of] equipment, [including] more than 20 x-ray machines, that are out of use, in addition to the ICU and operating theaters and physiotherapy and renal dialysis because of non-availability of the spare parts.” eDr Kashif, June 2014

3. Results 3.1. Effects of siege: materials and resources My research data demonstrated how the siege creates an extreme form of economic dependency, and while all sectors of the society are affected, the primary targets are the service providers of the Palestinian Authority (PA): the Ministry of Health (MoH). While siege separates Gaza from trading with the outside world, it also forces Gaza to be a captive market for Israeli goods. My field observations revealed to me how few of these sectors are more important, or more obviously distressed by this policy than the public health sector. Data showed that the most direct impacts from the siege result from an inability to import necessary medical items such as medicines, disposable items, and spare parts for machinery, along with a ban from the Israeli government on items needed to support industry and economic development. In addition, during my multiple years in the field, participants made clear to me that the health sector suffers from constant power outages and shortages of fuel for backup power generators and for vehicles as a direct result of the siege. Data from both my fieldwork and interviews demonstrated the ways the siege works to maintain Gazan dependency on Israeli goods, and to prevent the development of a local industry. Dr. Maqadma, the head of Gaza health services for UNRWA, explained how the Israeli government manipulates the siege to maintain this relationship: The siege may be loosened from time to time, but really, it is for consumption. There is no softening of the siege for the items that we need to develop our own economy or industry. But people need money to consume, to buy things. A good example of this is the building material. The raw materials for the small factories…The building material is under strict [Israeli] control to get into Gaza. eDr. Maqadma, 2014 Dr. Maqadma and his colleagues in the Ministry of Health explained that basic staples such as fuel, electricity, spare parts, and medicines are all controlled by the Israeli COGAT (Office for the Coordination of Government Activities in the Territories), or civil authority, a division of the Israeli military. Until 2009, COGAT allowed items into Gaza that were categorized into 42 types; all other items were prohibited (GISHA, 2010). After 2009, these limits were somewhat loosened, but my field work illustrated to me the many ways that, overall, the materials coming into Gaza are unpredictable, and goods often stay in the limbo of Israeli “processing” for months, and even years at a time. Dr. Kashif, who works as an international liaison with the Gazan Ministry of Health (MoH), described the impacts of the siege on imports: “[once the siege began], many of the hospitals that need[ed] maintenance could not continue because there [was] no raw material, no cement, no iron. [Today]the equipment that needs maintenance in laboratories, and x-ray departments, in physiotherapy departments, in the operating theater, in the emergency department, in the nurseries, the ICU, cardiac care units, doesn't

This observation from an administrator in the MoH reflected the data from other sectors related to shortages of supplies necessary for healthcare; interviews from staff from UNRWA and the NGO Al Awda hospital detailed similar effects of siege on medication. A doctor from a large private hospital reported: “There is a problem with medications for cancer, for diabetes, chronic patients, we don't have access to these medicines. Also for anesthesia, these medications are very expensive, and we don't have the budget to buy them on the local market…for disposables, when we cannot get the supplies we need, we have to delay the operations that use them until we can find them. This causes problems for patients who need the services right away. This situation is all because of the closure.” Dr. S The WHO specifically identifies the maintenance of medical products and technologies as essential to developing a functional health care system (World Health Organization, 2007). My interviews illustrated that the difficulty that health care providers across the Gaza Strip find in maintaining their equipment and providing access to modern medicine is a direct result of the artificial shortages caused by the siege. 3.2. Effects of siege: the healthcare system While providers readily spoke of the details regarding the lack of equipment and supplies, data from interviews highlighted the ways that challenges over material resources make apparent other issues related to de-development, particularly a weakening of service planning and of the level of coordination and cooperation among key organizations. These processes undermine several key components of quality health care, as defined by the WHO including strong leadership and governance; a well- organized service delivery system; and a responsive, well prepared workforce (World Health Organization, 2007). Until 1967, Palestine as a whole including Gaza, had been under a patchwork model of health care provision. In the 19th and 20th century, various parties led health services, including various missionary establishments; the British government during the Mandate period; the UN Relief and Works Agency (UNRWA), which was established in 1949 to respond to the 1948 nakba, or establishment of the state of Israel; and the Jordanian and Egyptian militaries (Giacaman et al., 2009). At the same time, particularly after 1948, Palestinians worked to establish their own networks of medical services (Giacaman et al., 2009). The Israeli occupation of Gaza that began in 1967 represented a specific historical shift regarding the politics of healthcare provision in the region. Under international humanitarian laws, particularly the Hague Convention and the Fourth Geneva Convention, Israel became the responsible party for managing the well-being of the occupied population when it invaded the West Bank and Gaza in 1967 (Takkenberg, 1991: p. 422). From 1967 until 1994, when the Palestinian Ministry of Health (MoH) was established under the Oslo Accords, the health system in Palestine was essentially “starved” (Giacaman et al., 2009:p. 844), a notion that certainly

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emerged in the data examined here: Health care under the Israeli occupation was fragile, and according to the minister of health at the time of the creation of the Palestinian MoH, there was no increase in beds in Gaza between 1967 and 1994. e Dr. Kashif, Gaza Ministry of Health, June 2013 After 1994, and the establishment of the Palestinian Authority (PA), Israel began to claim that it had no obligation to the wellbeing of Gazans as it considered health care the responsibility of the PA. Further, Israel now claims immunity to the responsibilities established in international law as it regards Gaza as a hostile entity, a meaningless term in international law (Bhungalia, 2010). The Palestinian Authority (PA) is not a state, and operates within parameters set by Israel. As such, data gathered from my participants made clear that it cannot represent an effective alternative to the Israeli obligations of health provision. The result of this vacuum of responsibility has been the establishment of a patchwork of healthcare providers. The five entities responsible for providing basic and advanced care include the MoH clinics and hospitals; NGO clinics and hospitals, the UN Refugee Relief and Works Agency (UNRWA); the military health system; and private clinics, doctors, and hospitals (Giacaman et al., 2003; Hamdan et al., 2003). These organizations are hampered by an overall lack of integration and communication, due not only to the realities of the siege regarding materials, supplies, and training as described in the previous section, but also to internal politics and the conditions imposed by donors and the international community (Giacaman et al., 2003; Giacaman et al., 2009). The challenge of diffused systems of care across multiple sectors originates not only from a lack of material resources, but how care is delivered by a large number of providers with varying agendas, capabilities, ideologies, and capacities (Alessandrini, 2002; Hamdan et al., 2003). Actually we have one stable thing in health services: the only stable thing is instability. We cannot actually arrange and plan for proper planning for health service in Gaza and West Bank because of the continuous crisis. e Dr Kashif- June 2014 While Hamdan et al. argue that MoH funding improved in the early 2000's (Hamdan et al., 2003: p. 64), in various interviews, participants across the health sector claimed that the MoH has suffered from a reversal of this trend in the intervening years. Participants pointed out that Israel refuses to provide the Palestinian MoH with funding commensurate with the Israeli funding of hospitals for their citizens, and instead delegates all responsibilities to the MoH, an institution that lacks the resources to provide health care for 1.8 million people in Gaza. As a result, foreign-funded NGOs and the UN are left to fill in the gaps. Further complicating the mission of the MoH, the West-Bank based PA government withholds funding from the MoH as a means of helping to destabilize the HAMAS government (Abu-Sada, 2011) The Ministry of Health is not HAMAS, it is a professional ministry. The MoH I will reassure you more than 90 percent are professionals. Doctors, nurses, technicians, they are not activists, they only take care of their patients. For health and education, I will confirm that there are no political affairs in these two sectors, because they are service ministries, they help all the people. They don't differentiate between parties in health care delivery. And we don't differentiate between parties in hiring consultants and doctors and nurses and technicians, and so on. e Dr. Kashif e June 2013 In line with this tension described by Dr. Kashif, interview participants referenced challenges with working with the MoH due to

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internal politics. Dr. Kashif explained that many of these problems relate to the punitive relationship between the elected de facto Gaza government of HAMAS and the unelected West Bank FATAHcontrolled PA. A director of an NGO hospital in Gaza City explained the issue. The problem with coordination is with HAMAS, and the international situation. A lot of international organizations are not allowed to work with this ministry of health. This hampers the ability of the MoH to work with other organizations e Director of NGO Hospital Through my conversations in Gaza, I observed that the MoH is further hampered by the assumption by many, including outside donors, NGOs and private health workers themselves, that the public sector is rife with inefficiencies and corruption e rhetoric that is fundamental to the justification of privatization under neoliberalism. Dr. Sweiti, director of an NGO hospital, utilized conventional neoliberal rhetoric to explain the differences in service from the private and public sectors, stating “the private sector in the developing world, not just in Gaza, is more efficient, and the quality of care is better because the attitude of the employees. The presence of corruption will affect the service in the Ministry of Health, but not us.” This analysis is belied by the fact that even NGO hospitals such as Al Awda and Al Ahli Arab Hospital paradoxically send patients they cannot serve to the public sector, largely due to budget shortfalls. We provide the services to anyone who comes, first we provide the services, then we ask them to pay. If they can't pay for services, then we will cover them. This creates a problem in our budget. At best, our budget covers 60 percent of equipment, maintenance and salaries. [We manage to function] by the voluntary work of our staff: sometimes we don't have salaries, but still we do the work. We have very advanced services and equipment, the best you can get under the siege, and patients pay less than half here what they have to pay for private hospitals. We have a full Intensive Care Unit, but we don't have the budget to operate it. We have a nursery with 6 incubators, but we cannot afford the budget. So we operate it a few hours a day. For the more intensive cases, we transfer them to Al Shifa [Hospital in the MoH], because the refugees, they cannot afford the cost of care here themselves. For one night, it will cost 100 dollars, the refugees don't have this money, so we transfer them to the MoH. e Dr. Sweiti As is evident from this interview, the mismatch between patients and budgets, staff, and supplies, causes a cascading effect, wherein private hospitals rely on the MoH for patients that need care outside of the few hours these specialized units are open. According to UNRWA staff, when the MoH cannot provide the services, or patients cannot afford the minimal fees charged by the ministry hospitals, patients will often move themselves to UNRWA. This is a long-standing phenomenon, wherein Gazans have turned to the private sector to cope with shortages in the MoH (Beckerleg et al., 1999). The fundamental problem with this phenomenon is that Gazans will seek medical care from any source that can provide it. My participants made apparent that this creates a chaotic system of overlapping medical visits, prescriptions, and treatment plans, many of which go unfulfilled due to lack of materials and staff. As my participants noted, clearly these dynamics make creating leadership and governance quite difficult in such a context. One director of a Gaza area UNRWA clinic explained

…when people they don't get the service for their medicine, or suppose I am a hypertension patient, I need my antihypertensive

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drug, I don't find it in the government health center, then I will see what is the alternative. If I am a Palestinian refugee, it is UNRWA… This has affected our ability to plan… last year 400 people [came] to my clinic per day... Today, I don't know, there'll come 600 maybe, tomorrow 700, day after tomorrow 800, so I don't know now how many to the area are now coming to me… I have shortages in drugs, medicine, sometimes reagent, equipment, all this kinds, it also will increase the load on the staff, doctors, practical nurse, midwife, this will affect the quality [of service that we provide]. While the overload of UNRWA poses its own problems to that organization, it also demonstrates the ways that siege undermines a spirit of cooperation, as evident from an interview from a director of an NGO hospital in Gaza who explained: UNRWA has its channels, its ways, it can get what it needs into Gaza. The rest of us, MoH, Private and Non governmental entities, we suffer so much from Israel's blockade… We have to delay our surgeries because we cannot get anesthesia, we cannot get antibiotics. It is the same for the Ministry of Health. e NGO hospital director A sense of jealousy and competition is apparent in these interviews, emotions provoked by the overall context of extreme deprivation. The anger in these cases is directed at other sectors, UNRWA in particular, in these interviews. I observed this type of frustration as it further isolated practitioners across various sectors from one another, thereby further fracturing efforts to provide comprehensive and inclusive health governance and leadership, the kind advocated by the WHO. Numerous medical staff expressed their desire for better coordination, but the obstructions generated by donors makes this coordination extremely difficult. As my interview notes reflected, UNRWA provides services to all of the refugees living in Gaza, which comprise approximately 80 percent of the population. According to Dr. Maqadma, UNRWA relies on foreign donors as well as country pledges to provide its operations budget. Interview data collected in the most recent years highlighted how, as of 2014, UNRWA suffered from dramatic budgetary shortfalls, due in part to a lack of interest on the part of donors and donor countries based on the re-prioritizing of funds in the Middle East given the dramatic crises in Syria and Iraq. There is a consequence to the shifting interest of donors in this context: In a time when we are facing financial constraints, the international donors now are directed to different part of the world. Most of them are directed now to what's happening in Syria. They are running in front of the camera of the journalists, and the media. But Gaza is not attracting the focus of the international media, so we are suffering from shortage of funds because of the donors are not fulfilling their commitments or their pledges to our organization, which is the main provider for all services in Gaza. e Dr. Maqadma, January 2015 Donor prioritization does not just affect the geography of donations, even for UNRWA, donors tend to prioritize tangible goods over salaries (Hudock; James and Mullins, 2004). Donor-driven agendas make agencies responsive to funders rather than the communities they are bound to serve, and is a symptom of a larger neoliberal dynamic (Hanafi et al., 2005). These neoliberal ideologies create concrete realities, wherein even private hospitals are unable to fund salaries, but have entire wings of donated equipment that sits idle due to lack of staff and lack of electricity, as indicated in Dr. Sweiti's testimony. This creates a dynamic wherein UNRWA is unable to hire full time employees according to demand:

We are in continuous shortage of manpower, not because of the unavailability of the market, but because of shortage of the funds. Donors are not in favor to pay money for manpower, they are in favor to pay money for something that could be tangible, could be buildings or equipment, for medical supplies, but not for salaries. e Dr. Maqadma In scenarios wherein doctors are facing impossible workloads due to the shift of patients from the government clinics, UNRWA takes various temporary measures, hiring short-term contracted medical staff to make up for immediate shortfalls: The job creation program is giving a chance for people to take money in return for their work for a limited period of time. So for us in the health department, we used to receive these candidates for one year. Of course this is dependent on the availability of the funds. If the funds are available, we can recruit more and more. At the end of the some period during the work, the funds could be exhausted or finished, so the program is suspended for some programs. e Dr. Maqadma Data from my observations highlight how the problems experienced by UNRWA are further evidence of the dismantling of a solid governmental sector for health care provision. UNRWA is attempting to fill the demand for primary health care services, but is not in the position of coordinating health care provision in the strip; this is the role of the public health system. Given the constraints placed on the MoH, however, Dr. Maqadma explained that UNRWA finds itself forced to fill in gaps for health care, even as it is incapable of doing so due to budget shortfalls and mission constraints. Rather than hire more permanent full time staff, UNRWA is forced to hire short-term contract workers. This can solve short term overloading at particular clinics or sites, but, as my data indicated, does not add to the overall capabilities or long-term health of the organization. 3.3. The crisis in the ministry of health My data made clear that the Ministry of Health has long had a Sisyphean task of providing health care under extremely trying circumstances; some of which are shared with other nations that suffer from the politics of neoliberal under-development (Hagopian et al., 2004). Analyses presented here illustrated how these circumstances have become ever more dire. Data gathered in the aftermath of the 2014 Israeli invasion suggest that the MoH appears to be at a breaking point. One of the most glaring contributors to the breaking point that emerged in my data is the phenomenon of brain drain e a particularly salient risk within political violence (Farmer, 2004). Dr. Kashif claimed that like many other underdeveloped nations, young Gazans are less likely to stay at jobs in the MoH, when there are options that promise far better remunerations, under much easier working conditions. The Government [can]not satisfy them because salaries are low, so we have the mixture, we try to compromise so the mixture that he is working in the MoH and he will be allowed for some hours a week to work outside. e Dr. Kashif June 2014 A challenge outlined by Dr. Kashif above is that there is a major problem with retention of quality medical staff in the Ministry of Health hospitals and clinics. In light of the multiple constraints under which the ministry functions, Dr. Kashif suggested the only alternative is to allow medical staff to moonlight in the private

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R.J. Smith / Social Science & Medicine xxx (2015) 1e9

sector, a compromise that participants noted has deleterious effects on the quality of care in both the public and private health sectors. Interview data demonstrated how this is compounded by a new wave of emigration of Gazan youth who are now leaving Gaza, having given up on establishing a life in the strip. The frustration of the people and the disappointment is extremely dangerous…the phenomenon which appeared in our society is the migration, people found a way to get smuggled to Egypt and then through the sea to different parts of the world. This never existed [before] in our society… after the war, the phenomenon started to be very clear. Young people are willing to seek new lives, all of Gaza is expecting another war, they don't think that the war is ended… when people don't have jobs, they don't have a future, they don't have any horizon, they leave. eDr. Maqadma, January 2015 In June of 2014, the Israeli military began a bombing campaign and ground invasion in Gaza it called Operation Protective Edge. In the aftermath of this campaign approximately 2200 Gazans lost their lives. The operation displaced as many as 500,000 people, and the Israeli military destroyed thousands of homes, including entire neighborhoods in Shajaiyeh and Beit Hanoun (UN OCHA OPT, 2014). This massive increase in casualties, coupled with the internal political conflict in Palestine, led the Ministry of Health initially to end all non-emergency surgeries (World Bulletin, 2014). In the aftermath of the attack, and in the context of continued political strife between the de facto government in Gaza and the Palestinian National Authority in the West Bank, the Ministry of Health shut down surgeries for the indefinite future. In December, citing a lack of funds and an inability to get basic medical supplies, the ministry shut down several clinics and hospitals entirely. We are coping with a shortage of drugs in the Ministry of Health and the bad situation of health services in the ministry of health. … now the surgeries are suspended in the ministry of health hospitals. I'm coping now as UNRWA with the surgeries in my contracted hospitals, my limited budget. So what can I do, I have no choice, and I gave a sort of exception to the contracts for those hospitals to receive those cases that are not included in my contracts. e Dr Maqadma e January 2015 As illustrated above, the result of the shut downs has been a dramatic increase in demand for surgeries through UNRWA rather than through the MoH. According to Dr. Maqadma, given the extent of the crisis at the ministry, UNRWA made an exception to its policy of only supporting documented refugees, and referred patients, regardless of their status, to its 7 contracted hospitals, including Al Awda and Al Ahli Arab Hospital. Dr Maqadma further explained that these exceptions were put into place in the aftermath of the 2014 invasion, a time when UNRWA again opened its doors to all patients and displaced people regardless of their registration status as refugees. Dr Maqadma asserted that while UNRWA received some emergency funding during the war, it did not cover all the additional expenses incurred. My data illustrated how this dynamic created a significant strain on the already limited budgetary resources available to UNRWA in the strip, as they are compelled by the near-collapse of the MoH to work outside of their regular scope.

4. Discussion The research described here illustrates the challenges of creating strong health systems in a context of enforced isolation and manufactured humanitarian crisis. The siege hampers healthcare provision due to the constant uncertainty of availability of

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essential funds, supplies, and services. Data shows how these and other difficulties encountered by medical staff impinge on both daily work and any attempts to organize for a strong, systemized health care infrastructure. The gutting of healthcare, particularly a public system, is accomplished through multiple, connected strategies related to the political conflict, as described by the data here. As my participants explained, strategies of de-development include hindering access to materials and resources, the ever-increasing need for healthcare agencies (public and private) to rely on outside donors, and the exacerbation of schisms and tensions among key players. The strategies of de-development described by participants reflect the ways the population is metamorphosed into a surplus population. Gazan society is continually divested of any of the underpinnings necessary for a well-functioning sovereign health care infrastructure (WHO, 2007). Instead of a self-governing, independent system, this analysis of health care structures in Gaza reveals a system that is at continual risk of being comprised entirely of captive consumers who are entirely dependent on Israel, international bodies, and the aid industry for goods and services (Tyner, 2013). In particular, data show a consistent marginalization of the Ministry of Health, which is characterized as not only an entity of corruption and inefficiency (the typical neoliberal rhetoric (Navarro, 2008)), but also as a terrorist entity. Due to attacks on the public health care system, Palestinians historically prioritized the private sector, including NGOs (Habasch, 1999). As the results presented here highlight, this trend has continued, and by supporting the private and NGO sectors, funders help to undermine the MoH, and create overlapping and uncoordinated competing health sectors. This, along with the unrelenting hits that healthcare systems take with regards to materials and staffing, complicates the process of developing strong local control and leadership in the health sector and results in infringing on several areas of functioning that are necessary for sound health systems, as determined by the WHO (2007). With regards to implications, efforts to support effective healthcare systems in Gaza should focus on the very real needs for staff and infrastructure, rather than a preference for short-term projects or tangible goods. Particularly in considering aid-based solutions, however, practitioners must be careful to acknowledge the tension that, while there is a need to identify and support organizations with the greatest chance of remaining committed to long term care, aid is only necessary due to Israel's refusal to honor its commitments under international humanitarian law, including the requirement for an occupying power to provide health services (Arts 55,56, Convention (IV) relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949). Aid is no substitute for the obligations that Israel has under such laws (International Committee of the Red Cross (ICRC), 1949). Furthermore, agencies providing aid are circumscribed by Israeli demands, and, scholars increasingly argue that aid agencies may well be complicit with siege policies by providing aid in a situation of imposed siege and deprivation (Abu-Sada, 2011; Erakat, 2011; Whittall and Neuman, 2014). Findings related to the schisms among NGOs, including UN bodies, and the MoH point to the special importance of understanding and combatting the effects of the various politics of aid that exacerbate the destabilization of the public sector, a phenomenon that is seen around the world (for an example of combating this, see for instance The NGO Code of Conduct for Health Systems Strengthening (Code of Conduct Coalition, The Palestinian General Union for Charitable Societies, the Palestinian NGO network, the National Institute for Palestinian NGOs, & Gaza, 2008; Health Alliance International et al., 2008)).

Please cite this article in press as: Smith, R.J., Healthcare under siege: Geopolitics of medical service provision in the Gaza Strip, Social Science & Medicine (2015), http://dx.doi.org/10.1016/j.socscimed.2015.10.018

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4.1. Recommendations Results speak to the need for efforts that support health systems through combatting the ways the siege affects health care. In a larger sense, though, findings illustrate that as long as the siege remains in place, the health of not only the Gazan population but also its critical infrastructure will continue to deteriorate. As one doctor noted, the effects of the siege not only contribute to growing rates of disease, but also cause “a deep injury in the heart of the people that is very difficult to cure.” Efforts to develop solidarity, particularly around the health effects of conflict, therefore need to be shaped by a nuanced reading of the geo-political nature and human impacts of the siege and occupation (Pedersen, 2002). It is this reading that the research presented here aims to enrich. As many health scholars analyzing Palestine point out, health care will remain in crisis so long as siege and occupation are in place, in spite of (or perhaps, because of) international aid (Becker et al., 2009; Giacaman et al., 2003; Giacaman et al., 2009). Similar to other conflict situations marked by practices of under- and dedevelopment, both the larger level solutions and those specific to healthcare provision must be determined by Palestinians themselves, and not by outside parties (Cliffe and Luckham, 2000; Featherstone, 2012). In light of the results and discussion presented here, on a large scale, this examination of healthcare provision in Gaza points to the need for support for the solutions proposed by Palestinians, whether that be an end to the divisions that classify Palestinians as non-citizens, and thus ineligible for the Israeli state medical system, or a real, independent state, with the concomitant solid governmental systems that are so vital to the assurance of the long-term health of populations (Farmer, 2004; Katz, 2001; Pfeiffer et al., 2008). Acknowledgments The author would like to thank the Gaza staff of UNRWA for all their support and assistance in providing interviews and opportunities for observation. The author would also like to thank Cindy Sousa for her general support, editing assistance, and her assistance with the literature review. References Abu-Sada, C., 2011. Gaza Strip: a perilous transition [Place of publication not €  identified]. In: Magone, C., Neuman, M., Weissman, F., sans frontiEres, MEdecins (Eds.), Humanitarian Negotiations Revealed: The MSF Experience. Columbia  € University Press; MEdecins sans frontiEres, New York. Alessandrini, M., 2002. A fourth sector: The impact of neo-liberalism on non-profit organisations. In: Paper presented at the Jubilee conference of the Australasian Political Studies Association. Australian National University, Canberra. Barghouthi, M., Giacaman, R., 1990. The emergence of an infrastructure of resistance: the case of health. In: Nassar, J., Heacock, R. (Eds.), Intifada: Palestine at the Crossroads. Praeger, New York. Becker, A., Al Ju'beh, K., Watt, G., 2009. Keys to health: justice, sovereignty, and selfdetermination. Lancet 373 (9668), 985e987. Beckerleg, S., Lewando-Hundt, G., Eddama, M., el Alem, A., Shawa, R., Abed, Y., 1999. Purchasing a quick fix from private pharmacies in the Gaza Strip. Soc. Sci. Med. 49 (11), 1489e1500. http://dx.doi.org/10.1016/S0277-9536(99)00212-9. Bhungalia, L., 2010. A liminal territory: Gaza, executive discretion, and sanctions turned humanitarian. GeoJournal 1e11. Cliffe, L., Luckham, R., 2000. What happens to the state in conflict?: Political analysis as a tool for planning humanitarian assistance. Disasters 24 (4), 291e313. Code of Conduct Coalition, The Palestinian General Union for Charitable Societies, the Palestinian NGO Network, the National Institute for Palestinian NGOs, & Gaza, t. P. G. U. f. N.-. (2008). Palestinian NGOs Code of Conduct. Craven, M., 2002. Humanitarianism and the quest for smarter sanctions. Eur. J. Int. Law 13 (1), 43e61. Di Muzio, T., 2007. The ‘art’of colonisation: CAPITALISING sovereign power and the ongoing nature of primitive accumulation. New Polit. Econ. 12 (4), 517e539. Erakat, N., 2011. It's not wrong, it's illegal: situating the Gaza blockade between international law and the UN response. J. Islamic Near East. Law 11, 37e85. Farmer, P., 2004. Political violence and public health in Haiti. N. Engl. J. Med. 350

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