As the two million Palestinian residents of Gaza enter their 11th year under a blockade imposed by Israel and Egypt, the many daily hardships they face are having an increasingly adverse effect on physical and mental health, particularly for the most vulnerable.

Life for the people of Gaza has become characterised by soaring unemployment, acute fuel shortages, electricity supply for a couple of hours a day, a crippled water and sanitation system, prison-like movement restrictions, and the ever-looming threat of full-scale Israeli aggression on the horizon.

Given the current local and international political landscape, conditions seem likely to deteriorate further, compounding adverse conditions for health and pushing a basic and fragile health system ever closer to collapse.

Fuel crisis

The largest potential catastrophe facing public health in Gaza is the latest energy crisis, which has left Gaza’s health sector on the brink of collapse.

Following the shutdown of the Strip’s only power plant after it ran out of fuel, Gaza’s 14 public hospitals and 16 health facilities now “face partial or complete closure of essential services”, according to the World Health Organization (WHO).

Gaza’s hospitals, operating on a limited reserve of emergency fuel, donated most recently by the United Nations, have partially closed a number of services to cope with the fuel shortage.

An electricity generator supporting Al-Shifa Hospital in Gaza City [William Parry/ Al Jazeera]

With Israel and the West Bank-based Palestinian Authority (PA) unwilling to supply more electricity or fuel, Gaza’s hospitals and health clinics will be forced to stop critical services – this will be immediately life-threatening for newborns in critical care, patients in intensive care units (ICU), and hundreds of haemodialysis patients. It could also compromise refrigerated blood and vaccine stocks.

Earlier this month, United Nations Humanitarian Coordinator for the occupied Palestinian territories Robert Piper expressed urgent concern about steps by the PA and Israeli authorities to further reduce energy supplies to Gaza, warning that if implemented, the situation would become catastrophic.

“A further increase in the length of blackouts is likely to lead to a total collapse of basic services, including critical functions in the health, water and sanitation sectors,” he said.

Nutrition and disease

Poverty contributes to poor health, and poor health can lead to poverty – it’s a vicious cycle. In Gaza, poverty is rife. At 41.1 percent, the unemployment rate is the highest in the world (youth unemployment is just shy of 64 percent), over a fifth of the population lives in “deep poverty”, and 80 percent of the population depends on international aid, primarily for food assistance.

Ard el Insan (AEI), a local NGO with centres in Gaza City and Khan Younis, each year supports thousands of children five and under, along with their families, in addressing the causes and outcomes of chronic and acute malnutrition. Its executive director, Dr Adnan al-Wahaidi, says that the blockade and war have left Gaza “at the edge of a cliff, absolutely vulnerable”.

He says cases of acute malnutrition with signs of severe wasting among young children in Gaza are increasing.But the real public health concern is chronic malnutrition, characterised by stunting and rickets, says Wahaidi, who has seen rates increase by about 50 percent over the past decade among children aged five years and younger, rising from nine percent to 13.4 percent of the population.

Gaza City residents queue for food aid vouchers at the UNRWA distribution warehouse [William Parry/Al Jazeera]

“Acute malnutrition is easier to manage: the intervention is easier and it is cost effective,” he told Al Jazeera, while chronic malnutrition during formative years “can lead to irreversible consequences and side effects that will affect the body’s physiological systems, including the immune system, as well as cognitive achievements and physical development,” he warns.

“These children will be a double burden, on their families and on society, requiring a lifetime of medical interventions for associated complications throughout life,” he says.

He adds that Gaza is witnessing other worrying trends – rising rates in younger age groups of non-communicable diseases such as cardiovascular disease, type 1 diabetes, and cancers. He says obesity among children is rising sharply as more families rely on cheap, high-caloric foods because they cannot afford basic, nutrient-rich foods.

Dark decade

Fikr Shalltoot is the Gaza director of programmes for a UK-based charity, Medical Aid for Palestinians (MAP). She has witnessed and worked to mitigate the enclave’s worst – “and worsening” – health crises for more than a decade.

She cites a long list of issues caused by the Israeli-Egyptian blockade: the latest fuel crisis; Egypt’s closure of the Rafah crossing; obstacles and delays in obtaining travel permits from the Israeli authorities for medical referrals outside of Gaza; chronic shortages of zero-stock drugs and medical disposables; extreme difficulties faced by medical professionals in obtaining permits from Israeli officials to get specialist training outside of the Strip; difficulties in recruiting international specialists to conduct trainings in Gaza; and outdated medical equipment or equipment requiring spare parts.

According to a 2016 WHO report, “nearly 50 percent of Gaza Strip’s medical equipment is outdated and the average wait for spare parts is approximately six months”.

Gaps in zero-stock medicines and disposables have remained chronic over past years in Gaza’s Central Drug Store [William Parry/Al Jazeera]

Shalltoot says the situation is “continually deteriorating”.

“I am always saying that last year was better than this year … at the end of the day, the people of Gaza are suffering.”

Over a third of essential “zero-stock” drugs and 30 percent of medical disposables are chronically unavailable, making treatment for many conditions, including chemotherapy for cancer patients, haphazard at best.

The problem is both a financial and political one between the Hamas government in Gaza and the Fatah-led PA in Ramallah, rather than Israel blocking the movement of these supplies into Gaza. As part of the PA’s ongoing attempts to pressure Hamas into giving up its rule of the Gaza Strip, it has not only halted payments for electricity and for its employees in Gaza, it has also halted shipments of essential medicines.

But regardless of the Palestinian political infighting, Israel holds the keys to Gaza and, as a besieging power, is responsible for what happens, Shalltoot says.

“Israel allows the drugs in, but they’re responsible for what’s happening in Gaza as the occupying power and for imposing the blockade and the consequences of this,” Shalltoot says.

“The enormous economic impact is Israel’s fault, as are the high levels of unemployment. The terrible financial situation in Palestine is a direct result of five decades of Israeli occupation.”

The military assaults have also cost the people of Gaza dearly, not only in terms of life and welfare, but financially: the 2014 hostilities inflicted an estimated $1.4bn in damages and $1.7bn in economic losses, according to the UN.

Access increasingly denied

Given the basic tertiary care available in Gaza, patients – particularly cases dealing with oncology, paediatrics, haematology, ophthalmology, and orthopaedics – are routinely referred to Palestinian specialist hospitals in occupied East Jerusalem and the West Bank, and occasionally to hospitals in Jordan and Israel.

These patients and their carers must apply to the Israeli authorities for permits to leave Gaza via the Erez crossing, known as Beit Hanoun to Palestinians.

The WHO has tracked a worrying decrease in the number of approved patient permit applications – averages of 77.5 percent and 62.1 percent in 2015 and 2016 respectively, dropped to an average of 54.9 percent between January and April 2017. Some patients died while awaiting permits to access outside medical treatment.

Patients who miss appointments must reschedule new ones and apply all over again for permits.

A UN report notes: “Patients … when delayed or denied access to specialised medical services, can suffer from deteriorating medical conditions which can affect their quality of life and contribute to death in some cases.”

Mental health

The blockade and three Israeli military assaults have had a profound toll on mental health in Gaza, too.

Substance abuse, suicide, domestic violence, depression, anxiety and post-traumatic stress disorder (PSTD) have increased among adults, as have bed-wetting, low academic achievement, nightmares, fear and anxiety among children, according to Dr Sami Oweida, a psychiatric consultant at the Gaza Community Mental Health Programme (GCMHP).

He also notes a rise in somatoform disorders – a form of mental illness in which a patient complains of physical ailments, including pain and fatigue that have no apparent physical cause.

According to a recent study published in PLOS ONE, a multidisciplinary research journal, Palestinians suffer the highest rates of mental disorders among all Eastern Mediterranean countries. The study attributes this to 50 years of occupation and exposure to related political violence.

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Dr Oweida says that work the GCMHP undertakes at their centre, coupled with outreach and capacity-building work with local partners, cannot keep pace with the demand.

“Any effective therapy is pointless because of the blockade – that is the root cause. The high levels of unemployment, especially among men, the traditional head of the family who can’t protect the family and secure its basic needs – that creates anger and frustration … and is often expressed through violence in the home,” he told Al Jazeera.

“People see no reason for optimism – they are trapped in a large prison. There is no horizon, no political solutions. The people anticipate a new military assault, it is always on their minds. There are constant reminders of provocation, through drones, sirens, destroyed buildings … It creates high levels of anxiety in everyone. Nothing will help, except ending the blockade and giving dignity back to the people.”