Abstract
Providing care for families under occupation has always been marked by scarce resources and too many patients. The current war in Gaza has dramatically worsened conditions in the Occupied Territories of Palestine (OTP). A family physician and her team in the southern West Bank describe their own challenges and give voice to the physicians in the OTP they interviewed to better understand the professional and personal challenges of living and working during the uncertainty of war.
Annals Early Access article
Primary care is the backbone of many health care systems around the world.1 With 15 years of experience in primary care, 6 of those as a family physician, and 4 as the director of family medicine in the Ministry of Health (MoH) in the West Bank, I (B.M.) understand primary care’s importance and the dimensions that family medicine adds to the field. Through my participation in the World Organization of Family Doctors (WONCA) and travel to primary care centers in other countries, I have realized that providing care under occupation is not easy. Likewise, the challenges of practicing primary care and family medicine amidst conflict are overwhelming.
The West Bank and Gaza have been under persistent military occupation since 1967. The health care system is fragmented due to different funding and administrative arrangements. These include: the occupying power, Israel; the Palestinian Authority; the de facto authority in the Gaza Strip; the United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA) which provides basic health services, education, and social services to Palestinian refugees; and nongovernment organizations (NGOs) affiliated with the international community.2 Most primary care is provided by general practitioners who complete medical school (6 years) and a rotating internship, predominantly hospital-based. Family doctors, who have 4 years of training in family medicine after medical school and the internship, are a minority among all primary care physicians.3
Before October 7, 2023 and the current war in Gaza, I faced many challenges in my MoH primary health care clinic. The primary care doctor sees at least 100 patients every 8-hour shift, 5 days a week. There is no appointment system. Patients do not see the same primary care doctor every time because physicians may work clinic X today and be assigned to clinic Y tomorrow. Patients are registered in multiple health care institutions (MoH, UNRWA, private), often seeking care where it is most expedient. These different institutions neither coordinate care nor use universal guidelines. Many specialized services are unavailable, and patients are referred to facilities inside Israel or another neighboring country such as Jordan. Any referral requires Israeli permission which may or may not be granted in a timely manner, if at all.
The constant lack of medications and laboratory tests add a significant burden, as patients return to the clinic again and again, asking for their missed meds since many cannot afford the out-of-pocket costs from the private pharmacy and laboratory. Mental health services are woefully inadequate.4 As a family physician, I am not allowed to diagnose depression, or any mental health disorder, or to prescribe any antidepressant. These patients must see a psychiatrist, and that requires a long wait.
As a result of these challenges, there are many gaps in providing evidence-based health care. I often question the quality and continuity of the medical care I provide. This tireless work is not enough to accomplish what is best for patients, resulting in high burnout rates among health care providers.5
With the current war in Gaza, chaos has reigned and life in the West Bank has also become much more difficult. The situation impacts me at work and home and has affected me mentally. I am also a researcher and published several papers with my US mentor (T.Z.) during my family medicine specialty training. She suggested studying how the war has affected physicians professionally and personally. As a research instructor in the College of Medicine at Hebron University, in the southern West Bank, we assembled a qualitative research group, including 2 students, to understand the challenges facing physicians. We obtained ethical approval from the College’s Institutional Review Board in December 2023 to interview physicians in the West Bank and Gaza. Fifteen physicians were strategically selected from geographic locations throughout the Occupied Territories of Palestine (OTP) who were engaged in clinic- or hospital-based practices. We spoke with them virtually or in person. The research will be published elsewhere, but we selected quotes for this essay. We want to give voice to the physicians in the West Bank who feel solidarity with their Gaza colleagues and share their experiences, as well as those of several Gaza physicians. Both areas in the OTP (Gaza and the West Bank) are victims of the war. Physicians desperately try to care for their patients despite the violations to their own rights under international law6 and the unknowns of the future. Although the West Bank is not the site of the war, atrocities perpetrated by the occupying army (Israel) and settlers cause challenges. A West Bank psychiatrist summarized life post-October 7, 2023:
“Life was not rosy before; it was not a life of justice and equality, and not everything was good for us, but the challenges have become bigger for all of us … this has to do with continuous trauma and its relationship to the future. Today, we are thinking about what the shape of tomorrow could be and what we will look like after 6 months.
West Bank physicians and their patients have difficulty accessing health centers due to more checkpoints, road closures, and searches at gunpoint. A usual 30-minute trip to work takes 4 and 5 times longer. Initially, many physicians traveled to work by ambulance since private cars were stopped but ambulance travel has become difficult since they are no longer granted the right of way. A family physician in the northern West Bank described the disruption to her government clinic:
The Occupational army have been entering and raiding the camps [Refugee camps in the West Bank were established by UNRWA in 1948.] … There was a time when they stayed for about 5 days, and we did not go to work. If you go, you feel like you are on an adventure …I have someone from my family watch the road for me so I can go … my children worry about me when I go to work.
Due to the travel challenges and no salaries, many patients have stopped coming to clinic for the management of their chronic health issues like chronic kidney disease and diabetes. Medications are in even shorter supply, unaffordable on the private market, and physicians constantly must figure out substitutes for the patients they do see. MoH reduced clinic hours to 2 days per work week, so primary care physicians attempt to complete the work of a 5-day week (100-150 patients per day) in 2 days. My own arm is so sore from writing hundreds of prescriptions that I started wearing a brace and asked to be switched to one of the rare clinics that has an electronic health record. Health care workers and physicians have not been paid in full for the last 2 years.
Hospital raids have become more frequent, especially in the northern West Bank. A family physician explained:
We have become afraid that at any moment, occupational forces could enter the emergency room and destroy it, along with everyone inside, just because they suspect that someone wanted is there.
This physician described a colleague’s advice to a relative with a stroke:
The hospital was besieged, he told her to stay home, I mean, a stroke is better than receiving a bullet, whether for her or whoever brings her to the hospital. ‘May God be with you. We will try to send an ambulance to her when the army leaves.’ And indeed, she stayed until the next day when the army withdrew.
Even patient’s attempts to reach West Bank hospitals emergently are routinely disrupted. One physician described a 10-year-old boy and his father’s ambulance trip:
It took an hour to reach the hospital between the checkpoints, and at the hospital, it took about 15 minutes for him [the father to carry the son] because ambulances are not allowed to enter. He [son] arrived at the hospital dead.
Physicians’ families are impacted as well. A primary care physician who lives in the northern West Bank described taking his own father to emergency after a day of abdominal pain that did not resolve.
Four of the 5 hospitals in the city were surrounded by the Israeli army, so we went to the one that was not. While my father was being evaluated, the army arrived and surrounded the hospital. My father’s workup was negative, and the pain resolved. Our decision was to wait until the army left and risk being stuck in the hospital all night, or to walk out with army snipers standing on the hospital’s roof and risk being shot. A journalist arrived and offered to walk with us. Given that journalists are being killed, we turned down her offer and opted to leave. Thank God, we made it home safely.
Israeli army raids occur more often in cities and refugee camps, resulting in fatalities and injuries that shutdown schools, shops, and activities for a day or more. A physician explained,
“There was that day when students were stuck in schools. I was here at the hospital … stuck here till 6:30 pm. My daughter was stuck inside her school.” Another described the impact on surgeries:
Many elective surgeries are postponed because the patient is unable to reach the hospital, and the accompanying person is unable to come with the patient. It has had a very deep impact, and of course, the overall situation in general, as the war is not far from us. We hear the explosions here.
A physician delineated the additional dangers for Palestinians who live close to the West Bank settlements: “They [settlers] are armed, routinely destroy property, attack Palestinians living in nearby villages and threaten to take property. The Israeli army, if present, does not stop them.”
Physicians also expressed grave concern about the next generation of Palestinians. They told us that it was impossible not to check the news and social media on their phones but tried to shield their children from the news. Despite such efforts, one physician reported:
“My son brought a toy gun to me and said, ‘I am Qassam (the name of Hamas army).’ He is 5 years old! When a small child lives in the atmosphere of war, he will not be a normal human being.”
Physicians worried about their families, their patients, admitted that they were emotionally exhausted, and unable to provide the level of care they had before the war. One said:
As doctors, because our work is inherently more human, these sights send shivers down your spine, even if you’re not a doctor, I don’t know, but we doctors are more emotionally affected … honestly, this had a significant impact.
However, like me, many physicians focused on the full part of the cup. One of the benefits during this time, is that family doctors from both sides of the OTP communicate and support one another. A resident family doctor in the West Bank explained:
At the beginning we were seeing what was happening with the doctors there [referring to Gaza] and communicating with the doctors. I mean, none of us could imagine what was happening, and every day we would say what is happening to them could happen to us, so we felt tense and fearful . . . And then we have to hold ourselves together where patients cannot come and find you distracted, because in the end, we want to live, whether here or there; we have to continue living. They [Gaza doctors] also teach us lessons, I mean, we talk [and text] to the [Gaza] doctors . . . they teach us, they are better than us, they teach us how to deal with their patients, how to deal with their families, and how they surrender their matters to God.
The ongoing war in Gaza has had a profound impact on West Bank physicians. None of those we interviewed were willing to talk about their own suffering until they acknowledged what was happening in Gaza. One said:
People say ‘I am eating and drinking. I want to offer something, I want to do something, but I am not able to do anything for these people in Gaza who are my family, my brothers, and my sisters. I don’t know where to start.’. . . it is collective helplessness. This feeling is harsh and very difficult to deal with.
The situation in Gaza has only grown worse. In December, a female family physician described her own losses:
An Israeli airplane struck our family home on October 10th. My mother, brother, and 5-year-old nephew were all murdered. My father and one of my brothers were both praying at the mosque. When they returned, the house was in ruins. My sister made it through. She spent 13 hours trapped under rubble before being rescued. She had a taste of death.
I have 4 children, but now I share a home with 23 other individuals. Together, we have a total of 14 children. We make every effort to save food and distribute it evenly. For example, during today’s breakfast, we offered each individual, young and old, half a sandwich to eat because nothing else was available. We were able to buy clementines for a large sum of money yesterday. We gave 1 to every 2 people. And so on; whatever we acquire, we divide among us.
Despite losing colleagues and family members, Gaza physicians continued to try to work amid the rubble, even though they were running low on supplies and medications. One family physician, 2 years out of residency, made a video to raise funds for a van when her clinic was destroyed, so she could go and check on her patients. She raised enough through international contacts and secured approval from MoH to open a medical tent with a family medicine approach in her refugee camp in the middle of Gaza at the end of January. Another family physician described the need to be flexible in the hospital early on, “One day as a general physician and 2 days in the burns and plastic surgery unit.” As demonstrated above, all spoke about trying to create some semblance of order for their own families.
Colleagues outside Palestine ask what they can do to help. There are no easy answers. War is not good for health whether in the OTP, Ukraine, or Sudan. Perhaps Dr Duha Shellah, a young physician from Nablus, said it best in her Lancet correspondence: “To speak up, stand for my oppressed people, and tell the world what normal looks like under oppression and occupation is my duty. Hear us. Listen to the people of Palestine.”7 Finally, a family physician summed up the sentiment of many of the physicians we spoke with: “We haven’t even started crying yet. We shall cry if the battle ends and we are still alive, I swear. We’ll cry until our eyes dry.”
Acknowledgments
We are grateful to the physicians who took the time to share their experiences and reflections with us. In memory of our colleagues and their family who have died during the current Gaza war.
Footnotes
Conflicts of interest: authors report none.
- Received for publication March 17, 2024.
- Revision received May 20, 2024.
- Accepted for publication July 22, 2024.
- © 2024 Annals of Family Medicine, Inc.
