Gaza’s health system is “completely eviscerated”—what happens now?
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj.r361 (Published 25 February 2025) Cite this as: BMJ 2025;388:r361
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Dear Editor
As the theme for World Kidney Day 2025 is to “Protect Kidney Health” it seems fitting to reflect on the impact of the destruction of healthcare facilities in Gaza on patients with kidney disease. Prior to October 2023, there were 1130 patients receiving dialysis in 7 centres with an annual growth rate in prevalent dialysis numbers of 13%. The current military offensive has left just 2 functioning dialysis units dialysing 715 patients. This has led to rationing of dialysis which in turn has caused to patients die from entirely preventable but fatal complications of kidney failure such as hyperkalaemia and pulmonary oedema. This has been further compounded by lack of access to medications, clean water, and insecure energy supplies. The results have been devastating with 44% of the prevalent dialysis population in Gaza being killed either through direct injury or being unable to access dialysis. Furthermore, it is likely that many of the estimated 450 kidney transplant patients have lost their transplants and have died due to lack of access to immunosuppressive medication because of the Israeli blockade1.
Before October 2023 there were only six nephrologists in Gaza, there are now just five of us left with two in exile and 3 remaining in Gaza. One nephrologist and 2 dialysis nurses have been killed directly by Israeli airstrikes in what the UN says is the deliberate targeting of healthcare facilities and workers2. We have all had our homes destroyed by airstrikes and lost many family members. Our bereavement whilst heart breaking for us is but a footnote in the tsunami of grief and loss that is afflicting the entire population in Gaza. Whilst it’s easy to get lost in the statistics, each life lost is precious, irreplaceable, and mourned.
In 2022 the American Society of Nephrology, the European Renal Association, and the International Society of Nephrology (ISN) issued a joint statement condemning the “shocking invasion of Ukraine by Russia” and expressed concern for those with kidney diseases3. Little over a year later in response to the destruction Gaza, these three societies said they would now focus on “actions, not statements”4. When one of the authors asked the ISN for practical support he received no response. The ISN Renal Disaster Preparedness Working Group has remained studiously silent about the deliberate destruction of dialysis infrastructure in Gaza by the Israeli army5. It is difficult to understand why the testimony of our lived experiences count for so little. This dehumanisation of Palestinians by our professional societies and the indifference of many peers has been a particularly bitter pill to swallow.
As we bear witness to the apocalyptic, destruction of healthcare and broader Gazan society we are reminded of Virchow’s assertion that “politics is nothing but medicine on a grand scale”. As a fragile ceasefire emerges the entire infrastructure for kidney care will now need to be rebuilt as part of a broader reconstruction of healthcare facilities. Until this happens, we are sustained by the words of our late colleague Dr Hamam Alloh, a nephrologist at Al Shifa Hospital who in November 2023 when asked why he hadn’t left Gaza responded, “You think I went to medical school and for my postgraduate degrees for a total of 14 years, so I think only about my life and not my patients?” Days later he and his family were killed in an Israeli airstrike. We stand on the shoulders of Dr Alloh and the over thousand healthcare workers who have been killed in Gaza since October 2023.
References
1. https://www.theguardian.com/global-development/2024/feb/17/patients-with...
2. https://www.ohchr.org/en/press-releases/2024/10/un-commission-finds-war-...
3. https://www.theisn.org/blog/2022/03/10/joint-statement-from-asn-era-and-...
4. https://www.theisn.org/blog/2023/12/14/announcement-from-asn-era-and-isn...
5. Al Jazeera English. Israeli soldiers smash dialysis machines. High risk patients go without treatment November 2024. https://youtu.be/vxVn4ZstqM8?si=wtfbriuGaxdQLS55
Competing interests: I'm from Gaza. I lost some of my colleagues, friends, neighbours. I lost my home. The hospital which I was working completely destroyed.
Dear Editor
Thank you for publishing the dire situation faced by the Palestinians in Gaza; advocacy is key in helping this occupied state until they are free of apartheid.
Would be helpful if we could have links of organisations so that those that do not have contacts can help where they can both directly and indirectly through virtual education in view of the destruction of the universities.
Competing interests: No competing interests
Re: Gaza’s health system is “completely eviscerated”—what happens now?
Dear Editor,
Thank you for this important article on the current situation of Gaza's health system. As we write this response, Dr Hussam Abu Safiya, the director of Kamal Adwan Hospital, is still being detained in an Israeli detention centre with reports that he is undergoing severe torture [1]. As you highlight, his case is not an isolated incident. Dr Adnan al Bursh, the head of the orthopaedic department at Al-Shifa Hospital, died after being brutally tortured in an Israeli detention centre [2]. Healthcare Workers Watch - Palestine has documented 264 cases of the unlawful detention of healthcare workers [3]. This is in the context of 3405 Palestinians being held in Israeli prisons without trial or charge as of 6th March 2025 [4].
The dire conditions in detention have significantly worsened for Palestinian detainees since 7th October 2023 [5,6]. Independent human rights experts report widespread abuse, with many testimonies describing detainees being held in cage-like enclosures, arbitrarily and regularly stripped naked, genital electrocutions, and other severe sexual and gender-based violence [5]. Numerous counts of anal rape have been documented [6]. These experiences will have long-lasting physical and psychological impacts including scars, fatigue, chronic pain, genitourinary complications, insomnia, depression, anxiety, personality changes, self-harm, suicide and post-traumatic stress disorder [7,8]. Complicity and active participation of some Israeli health workers in torture has been widely documented, as has the inaction of the Israeli Medical Association to take appropriate action [9–13]. Furthermore, testimonies given to the Euro-Med Human Rights Monitor document soldiers inviting civilians to watch, and record on their phones, the torture and inhumane treatment of Palestinian detainees [14].
There is overwhelming evidence of the brutality of Israeli forces towards Palestinian detainees, the majority of whom have been described as “de facto hostages of an unlawful occupation” by independent human rights experts [5]. After investigating Israel’s detention practices in 2023, the UN Special Rapporteur on the occupied Palestinian territory called for UN Member States to intervene on what she refers to as a “consolidated crime against humanity” against the Palestinian people [5]. Why, then, are we not seeing widespread outcry and meaningful action from the international community, including the medical community, to stop these atrocities?
This is the result of a long-standing campaign to dehumanise Palestinians (remember when Yoav Gollant, the previous Israeli defence minister, announced on 9th October 2023 that Israel was “fighting human animals” [15]). We see impacts of this dehumanisation playing out in the outcry among far-right elements of Israeli civil society (including ministers) in defence of the actions of Israel’s detention practices following the viral video of a Palestinian detainee reportedly being brutally anal raped [16,17]. Dehumanisation combined with active censorship of voices who attempt to highlight that these gross violations of human rights are not acceptable [18] and the silence of medical organisations [19] creates the perfect conditions to justify the arbitrary detention, torture and killing of Palestinian civilians. And it creates the perfect conditions for justifying the systematic targeting of healthcare workers and healthcare infrastructure [20].
The ceasefire in Gaza is only the first step towards justice for Palestinians that must include a meaningful and urgent commitment to ending the occupation. The international and medical community must activate its collective conscience and take action to stop Israel’s systematic violation of Palestinian detainees’ rights, including the arbitrary detention of Palestinian civilians and the pervasive targeting of its healthcare workers. Most of all, we must recognise that Palestinian lives, like the life of Dr Hussam Abu Safiya, matter and that we cannot and should not accept their arbitrary detention, torture and killing under any circumstances.
References:
1. Euro-Med Human Rights Monitor. Dr. Hussam Abu Safiya’s life in danger due to torture: Immediate international intervention needed for his release. https://euromedmonitor.org/en/article/6587/Dr.-Hussam-Abu-Safiya (accessed 14 January 2025)
2. Mahase E. Palestinian surgeon was assaulted before dying in Israeli detention, reports say. BMJ. 2024;387:q2672.
3. Qtati N. The Killing, Detention and Torture of Healthcare Workers in Gaza - Healthcare Workers Watch. Healthcare Workers Watch - Defending Healthcare Workers in Palestine. 2024. https://healthcareworkerswatch.org/publications/reports/the-killing-dete... (accessed 1 February 2025)
4. Addameer Prisoner Support and Human Rights Association. Statistics. https://www.addameer.org/statistics (accessed 7 March 2025)
5. Office of the United Nations High Commissioner for Human Rights. Israel’s escalating use of torture against Palestinians in custody a preventable crime against humanity: UN experts. https://www.ohchr.org/en/press-releases/2024/08/israels-escalating-use-t... (accessed 14 January 2025)
6. Addameer Prisoner Support and Human Rights Association. Update on the Conditions and Torture Violations Committed Against Gazan Detainees. 2024. https://addameer.org/media/5406 (accessed 14 January 2025)
7. Dehghan R, Osella C. The psychological impact of sexual torture: A gender-critical study of the perspective of UK-based clinicians and survivors. Transcult Psychiatry. 2022;59:380–92.
8. Kivlahan C, AlSharif M, Elliott I, et al. Long-term physical and psychological symptoms in Syrian men subjected to detention, conflict-related sexual violence and torture: cohort study of self-reported symptom evolution. EClinicalMedicine. 2024;67:102373.
9. Devi S. Israeli doctors accused of collusion in torture. Lancet. 2013;381:794.
10. Dyer O. Israeli doctors participated in torture, alleges released director of al-Shifa Hospital. BMJ. 2024;386:q1524.
11. Summerfield D. The campaign about doctors and torture in Israel five years on. BMJ. 2014;349:g4386.
12. Summerfield D. Is the international regulation of medical complicity with torture largely window dressing? The case of Israel and the lessons of a 12-year medical ethical appeal. J Med Ethics. 2022;48:367–70.
13. Physicians for Human Rights. Medical ethics and the detention of residents of Gaza since the start of the 2023 war: An ethical opinion paper. 2024.
14. Euro-Med Human Rights Monitor. ‘They brought Israeli civilians to watch our nude torture’: IDF torture of Palestinian prisoners is turned into entertainment for Israeli viewers [EN/AR]. https://reliefweb.int/report/occupied-palestinian-territory/they-brought... (accessed 14 January 2025)
15. Fabian E. Defense minister announces ‘complete siege’ of Gaza: No power, food or fuel. 2023. https://www.timesofisrael.com/liveblog_entry/defense-minister-announces-... (accessed 31 January 2025)
16. Graham-Harrison E, Kierszenbaum Q. IDF charges reservist with aggravated abuse of Palestinian prisoners. The Guardian. 2024.
17. McKernan B. ‘Deep moral deterioration’ being normalised in the Israeli-Palestinian conflict. The Guardian. 2024.
18. Khan MS, Tinua AT. Israel-Palestine: dehumanisation and silencing. Lancet. 2024;403:805–6.
19. Abbas S, Mitchell L. Australian medical leadership’s silence on Gaza is a moral failure. Lancet. 2024;403:1138–9.
20. Hagay Z, Borow M. Help Gaza with aid, not false designations. Lancet. 2024;404:122.
Competing interests: JA is the international advocacy officer at Addameer Prisoner Support and Human Rights Association.