This commentary is part of a Century International series exploring a shared future for Palestine and Israel that guarantees the fundamental rights of both communities. The Gaza war has exposed the bankruptcy of the existing policy frameworks. Our “Shared Future” series intends to spur conversation and promote new, better options for security, rights, and governance—for Palestinians and Israelis.

As Gaza reels from five months of Israeli bombardment that has killed more than 30,000 people, another profound crisis is underway. With its health infrastructure in ruins, Gaza is facing a public health catastrophe of a staggering scale. Starvation, mass pollution, and the spread of deadly infections have already begun.

Despite the war, Israelis and Palestinians are part of one epidemiological family. No matter one’s political attitudes toward Israel, Hamas, or the war, everyone should be concerned: the looming public health crisis will affect everyone in Gaza and it will not stop at borders.

Although relations between Israelis and Palestinians have never been worse, both sides need an immediate coordinated public health strategy, developed by Israeli and Palestinian professionals and backed by authorities to ensure implementation. Such cooperation might seem impossible in a time of war, but collaboration on health care cannot wait. As a material necessity, even a hardline Israeli government can politically justify such cooperation. At the same time, establishing systems of cooperation will strengthen the foundation for the implementation of any future comprehensive peace agreement, by creating working relationships and clarifying Palestinian–Israeli interdependence—making each side more invested in the well-being of the other.

The public health crisis cannot be resolved without a ceasefire, but there are also a range of actions that can happen even before a ceasefire, and which require Israel’s cooperation: entry of far greater quantities of medical supplies and equipment, medicines and vaccines; fuel, electricity, and water for medical facilities; reconstruction of hospitals in areas controlled by the Israeli military; and entry of additional medical personnel.

Israel’s ruling political elite is likely to reject any proposed formal cooperation with Palestinians, especially in Gaza. That decision would be self-defeating and untenable. The cold truth is that Israel has no choice: cooperative management of public health with Palestinians is a matter of sheer self-interest.

Cooperation with Israelis will be a hard sell among many Palestinians too, whether due to understandable distrust, anti-normalization attitudes, or political intimidation. But in Gaza, too, there is little choice. During the war, the minimalist coordination with Israeli authorities for a trickle of humanitarian aid is unlikely to change. But in the long term, expansive cooperation is needed for true rehabilitation of public health infrastructure and for a sustainable, comprehensive public health strategy.

Public Health Time Bomb

The public health crisis in Gaza could not be more dire. Following Hamas’s October 7 attacks, Israel’s war on Gaza has killed tens of thousands, including a high proportion of women and children. Gaza’s Ministry of Health also reports that the war has injured over 70,000, and displaced nearly 2 million Palestinians.

In the context of vast destruction of civilian infrastructure, the military assault has demolished health care in Gaza. Just one-third of hospitals were functioning by mid-February, according to the UN, and these are overloaded to 388 percent of their bed occupancy capacity. Just 13 out of 77 primary health care facilities were functional, and over 600 health workers had been killed. Some 93 percent of Gaza’s population was “facing crisis levels of hunger,” in the terminology of the World Health Organization (WHO).

Israel’s policies massively obstruct Gazans’ access to medical treatment. The UN has reported that Israel restricts the importation of medicine, supplies, and even drugs such as insulin pens for children.

Disease is now rampant. WHO has reported hundreds of thousands of cases of respiratory infections, diarrhea, skin rashes, chicken pox, meningitis, and hepatitis A. There is a risk of a measles outbreak due to lack of vaccine access, and cholera and other ills pose grave dangers.

Much of this crisis is not new. Israel’s nearly seventeen-year blockade on Gaza had already left the territory’s public health teetering. Long before the current war, lack of fuel for Gaza’s sewage treatment plants caused typhus and cholera, which threaten to spread to Israel. Gaza’s sewage pollutes Israel’s beaches and has caused numerous shutdowns of its desalination plants.

At various times during the blockade, Israel has prevented, limited, or delayed the importation of X-ray machines, computerized imaging machines for hospitals, and radioactive iodine needed for cancer treatment. Israel has delayed, sometimes for several years, the export of medical equipment for repairs by foreign manufacturers, affecting such areas as burn treatment, anesthesia administration, and CT scans. This is just a sample of such restrictions, which Israel justifies by saying that restricted items have the potential for “dual use” and could be diverted for military use.

Now, a public health catastrophe threatens to engulf both Gaza and Israel. Cooperation and ultimately a shared health policy is neither a luxury nor a feel-good activity—it is an essential need.

Health Can’t Wait for Peace

It bears repeating: only a ceasefire and a just peace can ultimately solve Gaza’s public health woes. But even without a ceasefire, there are several short-term measures that Israel must take—for the sake of Palestinian human rights, the health of all Palestinians and Israelis, and Israel’s international standing.

The risks to Israel of a health catastrophe in Gaza are manifold: Health care in Gaza is so poor that antibiotics have been overused, leading to the spread of drug resistant infections. And Israeli soldiers—to say nothing of Gazan civilians—have caught rare fungal infections and dysentery. A measles outbreak would threaten Israel too, especially given pockets of unvaccinated people in the population. Public health and disease control experts warn that diseases cannot truly be geographically walled in—all the more so as Israel unfurls plans to indefinitely occupy Gaza.

It bears repeating: only a ceasefire and a just peace can ultimately solve Gaza’s public health woes.

Another imperative for Israel is international law. Israel is facing charges of genocide at the International Court of Justice, and failing to stem the public health crisis will push the court closer toward a guilty verdict. Finally, the Fourth Geneva Convention holds occupying powers responsible for the medical needs of an occupied population. Israel argued that, after it withdrew the Israeli military and settlements from Gaza in 2005, it was no longer an occupying power in the territory—though the UN and other international bodies have determined that Israel still exercised effective control over Gaza.

But at present, it is indisputable that Israel is physically occupying the territory. Further, Benjamin Netanyahu, the prime minister, has released a plan for continued Israeli military control. Netanyahu himself argued as early as November that Israel must allow fuel into Gaza to power basic infrastructure. By December, his office stated that “minimal” support was necessary to prevent disease outbreak in Gaza.

Israel’s political leadership has taken what might be called a bare minimum approach to allowing medical supplies or infrastructure into Gaza, reflecting its general approach to humanitarian aid. Israel should immediately abandon this bare minimum approach and develop a comprehensive public health policy aimed at stabilization, rehabilitation, and cooperation—even during the war. This more expansive approach could include, for example, allowing more foreign medical personnel to enter instead of blocking them. To address the destruction of hospitals and death of medical personnel, Israel could allow Palestinian–Israeli medical personnel into areas in Gaza to support medical services, or to provide training and supplies. Israel should also revise the dual use categories to expand the entry of medical supplies.

Further, even during the war, such an approach should engage both Israeli and Palestinian public health professionals (ideally with experience in cross-border cooperation) to map out needs and coordinate activities, and official bodies with the authority to implement policy. These same principles, augmented by the principles of partnership and cooperation, should guide the evolution of a permanent, shared public health commission.

Israeli protesters block humanitarian aid trucks entering Gaza at the Nitzana crossing on February 27, 2024 in Nitzana, Israel. Source: Amir Levy/Getty Images
Israeli protesters block humanitarian aid trucks entering Gaza at the Nitzana crossing on February 27, 2024 in Nitzana, Israel. Source: Amir Levy/Getty Images

Better Long-Term Coordination

The crisis in Gaza presents extreme urgency, but Israelis and Palestinians will be facing extended versions of these same challenges for the foreseeable future. Long-term joint management of health policies is essential, and the precedents exist. But two aspects must change going forward.

First, a common health commission—comprising Israeli and Palestinian officials and public health professionals—should coordinate the numerous scattered forms of cooperation, involving governments, hospitals, and civil society. The aim would be to advance a comprehensive, big-picture public health strategy that would set short-, medium-, and long-term goals to maximize existing work. Second, policymakers leading the political framework—presumably Israelis and Palestinians, with international support—should develop a new policy built on equality and partnership between the two sides on all matters relating to public health. The existing political framework of coordination between official Israeli and Palestinian representatives currently prioritizes Israeli political and military control over Palestinians above all else. A common policy can take security into account, but decision-makers should understand that security is a mutual need of Israelis and Palestinians. And political control cannot be the guiding force for public health policy.

Political control cannot be the guiding force for public health policy.

A shared public health commission must aim to reduce health inequalities, which will benefit both populations. Such a body must be driven by professional knowledge, which requires the appropriate medical, public health, and epidemiological experts from both sides. But to be effective, a joint commission must be embedded in political institutions, so that it has “teeth”—the authority to implement policies within each side’s respective government.

The question of Palestinian representation is important, even though its shape is hard to predict. At the moment, no one knows what type of Palestinian government will emerge following the war, nor the identity of the Israeli government (or indeed, when Israeli elections will be held). But some Palestinians have advocated a technocratic, professional government for an interim phase, something Israel, too, could potentially accept. Such a case would create the best possible circumstances for public health cooperation. As Palestinians reconstruct permanent unified governance structures and institutions, these bodies should ideally include agencies designed for such cooperation. Israeli politicians should legitimize this kind of policy cooperation in governance, as well. Forward-thinking policymakers should develop and adopt these ideas, and ultimately legitimize them in the public discourse. Without this political framework for implementation, the commission risks being reduced to a recommendation agency, and its efforts dismissed.

Given the current hostile political environment, a permanent health commission will realistically only form in phases. It is important for leaders to eventually legitimize the importance of such cooperation. But in the immediate future, policy is more important than publicity. At present, public health policy should be viewed through the filter of shared public health needs, rather than through the prism of Israeli military victory and control, both during and immediately following the war. As soon as politically feasible, the political leadership on both sides should officially adopt existing civil society efforts for shared public health teams. International policymakers should take a firm position advocating that process. All early-stage public health cooperation efforts should form the core of a future permanent public health commission.

Guiding Principles

In my conversations with civil society activists and professionals involved in Israeli–Palestinian cooperation in public health, the following guiding principles have emerged as the basis for a serious and effective joint health commission:

  • permanent, long-term policymaking, rather than ad hoc, short-term strategies;
  • establishing strong, ongoing working personal and professional relationships, rather than ad hoc partnerships;
  • preventative strategies rather than only remedial measures (outlined below);
  • data and information sharing;
  • reducing inequalities in health care quality and access in general, to strengthen the foundation for disease or disaster readiness.

The commission should be responsible for policies in a range of fields. There are numerous Palestinian experts capable of leading the effort and sorting out the particulars. One leading thinker on the issue is Yasmeen Abu Fraiha, who is a Palestinian physician and a specialist in internal medicine, a critical care fellow at Boston’s Beth Israel Deaconess Medical Center, and a research fellow at Harvard’s Middle East Initiative. Abu Fraiha is also a public health expert, and served as the health policy director at the Israeli Ministry of Health’s Task Force for Health Promotion in Arab society. In her work, she has expanded on the areas that require extensive cooperation because they are textbook cross-border issues.

Drawing on Abu Fraiha’s thinking and input from others, a list of shared public health responsibilities could include disease prevention, including vaccine access, distribution, and protocols, training, and lab techniques. The commission could similarly address disease containment measures and policies for pandemics, and adopt common policies to prepare for natural disasters, such as floods or earthquakes, which carry public health consequences. A shared commission can develop and harmonize medicine and drug standards and licensing. It can also continue to coordinate exchanges for treatment and training, with the aim of reducing inequalities in health care. Another long-term aim Abu Fraiha has discussed is the development of policies to reduce pollution and emissions from health care systems.

Further, while such a commission most likely cannot be established during the war, policymakers should aim to establish the body in the near future, which will entail working in harsh postwar conditions. Health cooperation cannot ignite a politically led peace process, but the commission should be oriented toward the values that will stabilize the situation, such as reducing inequalities of conditions and resources that affect public health. And while in the past it has mostly been Palestinians seeking Israeli training and treatment, the commission should prepare for a time when Israelis might participate in Palestinian health care, or Palestinian and Israeli health care bodies collaborate on programs for visiting foreign medical professionals.

Precedent for Cooperation

Cooperation may seem far-fetched in the current circumstances, but there are plenty of precedents to draw on. It’s mainly the political frameworks and balance of power that need to change.

At present, the Israeli government and the army regulate or heavily restrict the flow of people and goods into the West Bank and Gaza (during the war, Israel has almost effectively sealed off Gaza). The Coordination of Government Activities in the Territories (COGAT) and the Civil Administration—both under the authority of the military—have a specific unit and individual personnel dedicated to health and medical issues for the West Bank and for Gaza. This body coordinates with the Palestinian Authority and Israeli ministries of health to approve or deny patient entry permits, for example. Coordinating the importation of medical equipment can involve the Israeli Foreign Ministry as well. In 2021, the ministers of health and environment from Israel and the Palestinian Authority met to revive cooperation, in a short-lived Israeli government. Yet in a political framework dominated by Israel’s occupation, these existing systems have fed drastic inequalities in Palestinian and Israeli health care services, while deepening Palestinian dependency on Israel. Still, the precedent for coordination exists.

Health collaboration is a vital necessity and important public good in its own right.

The Oslo Accords of the 1990s envisioned actual cooperation on public health and other areas, and established civil liaison efforts. At the time, the health ministries established the Public Health Joint Committee, to work on vaccine distribution and standards, disease prevention, data sharing, and cross-border hospitalizations. During the Second Intifada of the early 2000s, the effort began to peter out.

Still, Israeli and Palestinian hospitals continue to coordinate for thousands of Palestinian patients to enter Israel for medical treatment, including from Gaza. (Not that access is easy—Israel rejects many Palestinians’ applications to enter for health care, and the applications of their companions, which can make it impossible for a patient to travel in practice.) The Palestinian Authority Ministry of Health must approve medical insurance to cover such hospital costs, which is another area that requires coordination.

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Numerous civil society and nongovernmental organization (NGO) projects focus on public health, medical care, or professional training. These projects entail cooperation with Israeli and Palestinian professionals and require coordination with authorities—even with Hamas as the de facto authority controlling Gaza’s health and hospital administration. A sampling of projects includes cooperation between Physicians for Human Rights Israel and the Gaza Community Mental Health Program, on mental health issues related to Gaza’s closure. The Peres Center has medical training and mentoring programs for Palestinian doctors in Israeli hospitals (which also contributes to treatment of Israeli patients). Healing Across the Divides supports Israeli and Palestinian NGOs cooperating on the occupational health of Palestinian workers in Israel. Private sector companies have been involved in importing medical equipment, and the Israeli–Palestinian Chamber of Commerce has established an Israeli–Palestinian health forum.

Two specific ad hoc instances of public health corporations demonstrate the need and potential for coordination.

In 2006, a consortium for disease prevention involving Israeli, Palestinian, and Jordanian public health professionals took swift and successful action to contain the spread of avian influenza in the region. The consortium had been established several years earlier, initiated by two international NGOs, with the direct involvement of three ministries of health and the relevant professionals from public health services and ministries of each side. These actors had been convening to share data, and to participate in joint training programs for disease prevention and lab technology. The participants therefore had developed best practices and had strong working relationships, enabling rapid action to contain avian influenza.

In 2020, when COVID-19 began to advance, Israel and the Palestinians again confronted the reality that they represent one “epidemiological family,” in the words of the 2006 consortium participants. Despite the default boycott of Hamas authorities, Gazan medical personnel quietly entered Israel for training. The effort would have required de facto coordination between the Hamas-run Gazan Health Ministry and COGAT. But ultimately, the health care gaps between Palestinians and Israelis led to a significantly higher death rate among Palestinians than Israelis, according to data collected by Abu Fraiha.

A Public Good for All

The recommendations here can only advance in earnest once the two sides have reached a ceasefire, but immediate cooperation cannot wait. In the longer term, the work of such a commission depends on ease of access and movement, recognition of intertwined populations, and a political framework for resolving the Israeli–Palestinian conflict with built-in mechanisms for needs-based partnership between two states.

Even if it doesn’t contribute to broader cooperation, health collaboration is a vital necessity and important public good in its own right.

No matter how long a future political agreement takes, certain shared challenges will forever span both geography and politics, such as security, economy, public health, natural resources, and the climate crisis—at a minimum. And for any future agreement to succeed, the foundation for equality and needs-based partnership must be laid now.

Header Image: People inspect the damage caused by an artillery shell that hit the maternity hospital inside the Nasser Medical Complex, on December 17, 2023 in Khan Yunis, Gaza. One person was killed and others injured when a shell hit the hospital’s children and maternity ward. Source: Ahmad Hasaballah/Getty Images