A freeze on aid entering the Gaza Strip, imposed by Israel last week, means once again tons of urgent medical supplies and medicines are stuck at the border, with delivery uncertain.

But supplies are only one part of the picture, and their usefulness is limited without trained health-care workers who know how to treat and care for patients.

Health-care workers are the most critical component of any health system. Despite being protected under international law, they have been killed and injured at alarming rates in Gaza since October 7 2023.

There is also growing evidence of inhumane treatment and abuse of health-care workers in Israeli detention. This has serious implications for the health of Palestinians, in both the short and long term.

What is the state of the health-care system?

The health system in the Gaza Strip is in ruins. The Israeli Defence force has carried out at least 670 attacks on health services and facilities since October 7 2023.

The most recent World Health Organization update in February reported only 50% of hospitals were partially functional, and 41% of primary health-care facilities (for example, general practice clinics and pharmacies) were functional.

The latest report by the United Nations Relief and Works Agency for Palestine indicates only four out of the 22 health centres it runs are operational.

This widespread and systematic destruction of health infrastructure and equipment puts health professionals and their patients in immediate danger. Shortages of medical supplies and lack of reliable electricity and water make it harder for health-care workers to provide care.

What about health-care workers?

More than 1,000 health-care workers – including nurses, surgeons and other clinicians, paramedics, pharmacists and technicians – have been killed in Palestinian territories in the last 17 months, according to estimates by the United Nations and Palestinian monitoring group Healthcare Workers Watch.

In September last year, a UN inquiry found Israeli security forces have deliberately killed, wounded, arrested, detained, mistreated and tortured medical personnel and targeted medical vehicles.

The latest report from Healthcare Workers Watch documents 384 cases of unlawful detention of health-care workers in Palestine since the current war began, 339 of them from Gaza.

Of these, 96 have provided testimonies of inhumane treatment. At least 185 are known to remain in detention and 24 are missing after hospital invasions.

Physicians for Human Rights Israel and The Guardian have also documented testimonies of medical personnel released from Israeli detention. Many say they were detained while carrying out medical duties.

They report being subjected to interrogations without legal representation, medical neglect and starvation, abuse and torture.

One senior consultant surgeon, Dr Issam Abu Ajwa, told journalists from The Guardian and Arab Reporters for Investigative Journalism he was arrested while performing surgery and then detained for months without charge.

He alleges prison guards were given instructions to deliberately damage his hands: “They said they wanted to make sure I could never return to work”.

The Israeli Defence Forces (IDF) did not respond to the individual allegations but told The Guardian “suspects of terrorist activities” have been arrested and detained during fighting in the Gaza Strip. In a statement, the IDF said: “Those who are not involved in terrorist activity are released back to the Gaza Strip as soon as possible”.

The UN High Commissioner for Human Rights Volker Türk has said Israel’s claims hospitals are being used for military purposes are vague, unsubstantiated and “in some cases, they appear to be contradicted by publicly available information”.

What does this mean for people in Gaza?

Before October 7, Gaza’s health system was already unable to meet the needs of its population. The escalation of those needs due to the bombardment and reduced sanitation in a shattered health system is catastrophic.

Losing health-care workers – whether they are killed, injured or incarcerated – further depletes an overburdened system. As a result, ordinary people have reduced access to skilled and qualified personnel. And so do junior medical staff, meaning they miss out on opportunities to learn from the experience of senior staff.

All residents of Gaza, including health-care workers and their families, face serious threats to their health. A lack of adequate sanitation, nutritious food and safe water compounds other issues, such as increased risk of respiratory and diarrhoeal diseases, as well as complications during pregnancy and birth.

The UN estimates 50,000 women are currently pregnant in the Gaza Strip, with about 5,500 due to give birth in the next month. About 1,400 of these will require a caesarean section.

What about the long term?

Israel’s freeze on humanitarian aid, and the threat of resuming aerial bombardments, makes the planning and delivery of health services increasingly difficult.

In a population of 2.1 million there are large unmet needs from pre-existing conditions. The UN estimates 45,000 people in Gaza have heart disease, 650,000 have high blood pressure, more than 2,000 are diagnosed with cancer each year and more than 485,000 have mental illnesses.

Many more diseases will emerge in the aftermath of war. We have already seen a resurgence of polio in Gaza.

Without enough health staff, there is reduced capacity for public health surveillance and control – for example routine screening services and immunisation programs – and this increases the risk of disease outbreaks.

Health workers also play a vital role in training the next generation of health professionals. Disrupting this chain makes it harder to rebuild the health workforce and the health system more generally.

The impacts of war can’t simply be calculated in terms of fatalities, injuries and damaged health-care centres or facilities.

What’s also damaged is a shared commitment to humanitarian principles and the respect for human rights and international law.

Tania King receives funding from the Australian Research Council, National Health and Medical Research Council, Medical Research Future Fund, veski and Suicide Prevention Australia.

Fiona Stanley receives current National Health and Medical Research Council and Australian Research Council funding as a mentor not Chief Investigator. I am retired University Professor and Institute Director - now only Patron.

Guy Gillor is a Jewish-Israeli-Australian researcher and policy analyst that has advocated for justice and equal rights in his homeland of Palestine/ Israel from a young age, and is currently involved with a number of Jewish-Australian anti-war campaigns. Guy currently works as Manager of Strategy Policy and Research for an Aboriginal Community Controlled Organisation.

Rob Moodie is affiliated with the Medical Association for the Prevention of War (MAPW - national councillor) and Quit Nukes. He has received funding from National Health and Medical Research Council.

Tilman Ruff is affiliated with International Physicians for the Prevention of War (board member), International Campaign to Abolish Nuclear Weapons Australia (board member, co-representative to International Steering Group), Medical Association for Prevention of War (international councillor), Treaty on the Prohibition of Nuclear Weapons Scientific Network (member), Initiative for Peacebuilding, University of Melbourne (board member).

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