Good morning and welcome to Global Perspectives.

From our studios in Orlando, I'm David Dumke.

Today we are joined by Dr. Yara Asi who is an Assistant Professor of global health at University of Central Florida.

Welcome to the show.

>>Thanks for having me, David.

>>So Yara you are an expert on conflict and health connections, but you've been obviously tracking the Palestinian situation in Gaza, not just the current situation, but you've been tracking it for some time and you've done comparative studies between Jordan and Palestine, among other things.

Since October 7th, there have been, as of as of now, 23,000 deaths in Gaza, in addition to 59,000 casualties and a disproportionate number of those have been women and children.

Tell us about what's going on for the population.

And we're not I'm not asking you to do a political analysis here, but to look at the public health aspect, the needs of the people.

>>Yeah, well, thank you for inviting me to talk about this issue.

You know, as you note, prior to October 7th, the health situation in the Gaza Strip was already not in a good place after 15 years of blockade.

There was significant shortages in medical equipment, difficulties in medical training, medical staffing.

In 2012, the U.N. issued a report that, based on trend lines at the time, the Gaza Strip would be unlivable by 2020.

So it's important to have this context in mind when we consider the scale and speed of which things have deteriorated since October 7th.

So, as you know, tens of thousands dead and there are thousands more estimated to have been in those counts or under the rubble and tens of thousands of casualties, including significant burns, amputations of infants, including children, elderly.

It's an estimate that at least ten children per day have lost a limb since the war began.

So, of course, the airstrikes have caused a significant amount of this damage.

But now, increasingly, public health experts are really worried about the deterioration of the conditions.

As you know, Israel instituted a complete siege almost immediately after the attacks on October 7th.

And this has significantly kept out food, water, fuel, medicines.

Eventually, some trucks were allowed in, but not enough to meet demand.

And I'm sure we'll get more into the aid situation.

And so people are now living in significant poverty.

Starvation conditions for many people, including children, people with injuries from the airstrikes and bombing.

Obviously, many of them cannot get their medical needs met and they're having amputations without anesthesia.

Women are delivering babies without a medical professional.

But we're increasingly worried about the indirect causes of death that will come from these conditions.

So as people in Gaza have fled from the north to the south, the south has become increasingly overcrowded and it has not been spared from bombings.

So we have these extremely physically insecure populations crowded together in under-served facilities, extremely crowded.

I can't emphasize enough how crowded perhaps one bathroom per 300 people, lack of water, again, lack of fuel.

And so we're really concerned about infectious disease risk in these conditions.

It's already been reported that we're seeing increased cases of diarrhea, of influenza, increasingly COVID 19, these kinds of respiratory ailments.

As winter approaches.

It's estimated that if things continue at this rate and these people continue to be displaced and in these crowded conditions, up to a quarter of the population in the next year could potentially lose their lives, not from airstrikes.

So it's harrowing by any measure.

>>Going back to before October 7th.

Give us a picture of what the health situation was in the Gaza Strip.

Specifically.

You had a number of operating hospitals.

>>Correct.

>>But you still had restrictions in what could come in and out, including people.

>>Mm hmm.

>>What was the health care services like before October seven?

>>Sure.

So you have a very fragmented health care system in Gaza.

You have a very hobbled Ministry of health, which runs public facilities.

You have-- >>You have just if I could interrupt for a second, you have the Ministry of Health, which, of course, is the Palestinian Authority.

>>Correct.

>>Health.

But you have Gaza, which is under control of Hamas government, as opposed to the Ministry of Health in the West Bank, which is under the control of the Palestinian Authority.

>>Correct.

But in terms of health, more so than other ministries, there's a lot of coordination between the officials on both ends.

So licenses for doctors, for example, come out of the Palestinian Authority Ministry of Health, and it's the Palestinian Authority that's responsible for transferring pharmaceuticals.

So although, yes, there is a split in the governments in terms of health coordination, there was more, you know, going back and forth between the sides.

So because of the blockade, health care services are simply not available in Gaza.

So if you are diagnosed with cancer, if you require an advanced brain surgery or heart surgery or something like this, Israel maintains what they call a dual use list, which is a list of materials that they claim can be used for both civilian and military purposes.

But some of the items on this list have been and this is since the blockade in 2007.

Some of the items on this list are, however, extremely necessary for a functional health system.

Cement, lumber, types of rebar pipes, water pipes and other medical equipment.

There's been at times shortages of gauze, of I.V.

bags, of very basic medications.

And that's just for for everyday people.

If you had an advanced ailment, there was very few facilities in Gaza that could treat you, especially because the very advanced medical equipments like CAT scans, PET scans Israel does not allow into Gaza.

So what many people with these ailments are required to do is apply for a medical permit through Israel to be able to leave Gaza, to go either to the West Bank, to Israel, in some cases to Egypt to receive the care they need there.

I mean, I've written a lot about the medical permit system.

Even before October 7th, there were dozens of cases per year of children and others who have died while awaiting their permits.

You know, this is just one angle of the deterioration of the health system.

So going back at any point, really, and even before the official beginning of the blockade, because there was movement restrictions before Hamas took power, I mean, I said earlier in this, you know, the health system has collapsed since October 7th, but it's been collapsing for almost 15, 20 years.

It's been very difficult to get care.

And many people in such situations simply avoid care altogether.

So it's not uncommon to hear anecdotes of people who are diagnosed with advanced ailments, who simply know that the hassle of applying for the permit, getting the permit, you need a permit for each appointment.

So you can imagine if you have something like cancer, you don't go once, you have to go consistently, you need an escort.

It was a very complicated, confusing system, very, you know, lack of resources.

And lastly, for medical professionals, because they could not easily leave Gaza.

There was some specialties that they're unable to train and so they may wish to go to a university in in Europe or in the Gulf or in the US to take trainings or get get a residency elsewhere.

It's very difficult for them to do that.

And conversely, it's very difficult for external medical professionals who may wish to enter Gaza to provide trainings or offer certifications to do so because of the restrictions.

So on every level, from personnel to goods to even the basic resources needed to build a hospital, it's been very limited.

>>Well, obviously the situation has grown much worse since the conflict erupted.

Now you're talking about a population that's 85% who are displaced from their home in an area that wasn't that big to begin with.

>>Right.

>>Something roughly equivalent to Washington, D.C. proper with 2.2 million people, at least 1.9 million have been displaced since the conflict began.

You're talking about diseases spreading.

What are we going to see in the coming months?

And then who's pushing to?

You hear a lot of talk about we need to increase humanitarian assistance.

There's still restrictions in what can go in and out, even if there were enough able to go in.

What are the most pressing needs and what can be done about it?

Or is all this really putting a Band-Aid of the problem to you can get a situation of a ceasefire or certainly a more permanent agreement of some kind?

>>Right.

Well, you know, we have heard leaders and spokespeople from every humanitarian agency you can name.

Doctors Without Borders, every U.N. agency, Oxfam, Mercy Corps, Save the Children, are saying that this is amongst the worst conditions they have seen.

And these are people who have been in Syria, in Afghanistan, in Iraq, in Myanmar.

You know, any disaster.

So they're telling us that the speed at which this deterioration has happened is unprecedented.

And so if it continues at this pace, surely we will see deaths from airstrikes increase.

We are seeing now a situation where in the north of Gaza, almost nothing remains.

Almost all houses have been damaged and destroyed.

Most of the specialized health facilities that did exist in the Gaza Strip, you know, there was a cancer hospital that was built after significant work from donors.

They've all been destroyed.

How how and when are those rebuilt?

How are these homes rebuilt?

I think to begin with and again, echoing what the World Health Organization and many other humanitarian agencies have said, the starting point needs to be a cease fire, an end to violence.

And the problem at this point, however, as we speak, it's been about three months.

Even if there is a cease fire in one minute and there's no indication that there will be, we will still see significant death tolls in the coming weeks and months just from these displacement conditions.

I to be honest, I am not sure where exactly these people will be expected to go.

I mean, obviously, the fear for people in Gaza, those who have at this point survived and maybe have the resources to be able to leave to go to Egypt or Turkey, it's hard to describe the desperation of these conditions.

And we've passed the point where I think a cease fire is all that's needed.

Ultimately, of course, a political resolution is what's genuinely needed for these people.

But people in Gaza are afraid to leave because they're afraid they won't be able to come back.

And people that are there now are afraid they have nowhere to go back to that even if the war ends tomorrow and they're able to go back to the north, that nothing is waiting for them.

Every university has been destroyed.

Children have been out of school for this entire time.

It's a completely destructed society from not just the infrastructure, which is what is easy for us to see in photos and videos, but every aspect of life.

And there is no easy solution to this.

So in past Israeli military campaigns in Gaza and there's been about five since 2007, you know, donors step in and they make pledges, especially the Gulf states.

Almost every time these pledges are not met fully.

So that's an issue to contend with because there's so many global crises going on that donors are being asked to pay for.

And I think especially when it comes to Gaza, we're hearing donors say, you know, at this point, I have rebuilt the same hospital multiple times, the same green house.

It keeps getting destroyed.

So they're understandably hesitant to simply make continuing pledges with an assumption that this will not be the last time this happens.

And this level of damage is much more significant than any past campaign.

So there's really significant questions that I don't know how to answer at this point.

And I think that is one of the biggest struggles for the humanitarian community, is if we just want to serve patients needs, we can get them in a hospital in Egypt.

We can, you know, temporarily maybe find a solution for them, a house for their families.

>>These are temporary measures.

>>These are temporary measures.

Exactly.

And you know better than most how the burden of refugees across the Middle East has increased significantly since just 2000 with the Iraqi refugees, Syrian refugees and countries that simply don't have the infrastructure to take in more refugees.

And they don't feel that these people should be permanently displaced.

So it's not just a question of logistics.

There's a lot of other concerns that go into what comes next for these people.

But going back to your question, I think the first step would be a cease fire.

>>When you you're reading reports about malnutrition among and the rates of children being injured, I mean, obviously there are those who have been killed by by bombs and by actual violence.

But talking about disease and things like that, how is this affecting children in particular?

>>So even prior to this campaign, water borne illness was one of the top killers of children in Gaza because of just poor sanitation and not great access to clean water-- >>Is there safe water right now?

>>It's coming in through trucks.

And we've heard people, you know, the families that have survived, they are waking up at three and 4 a.m. to get in lines for a distribution of water so they're able to get it, sometimes increasingly less so in some days.

We've seen reports from families that have not been able to get food or water.

Definitely.

>>So I interrupted you to ask about the water question.

But you're talking about children.

>>Yes.

So the the water borne illnesses was an issue before due to the deterioration or the preexisting circumstances.

And so what we're seeing and you know, the UNICEF, which is the UN Agency for Children, has called Gaza a graveyard for children.

And as you say, it's not just from airstrikes, but children are being displaced from their homes at unprecedented rates.

Children are being born in unsanitary, unsafe conditions.

We have reports that tens of thousands of children have lost at least one or both parents.

Some children have lost every family member besides them.

They are the last surviving family member.

One of you know, I read a lot of reports from physicians in the hospitals there, and they say this is the hardest part of their job is when are casualties are brought in from a bombing.

They receive a child.

They know that no one else has come in with that child and they have to be the one to tell them.

When we talk about the future and when we talk about permanent solutions, we have to understand that for these children that their life as they knew it will never be the same.

And who will be responsible for them.

This is an open question.

When we consider other effects like diarrheal diseases, which are very common and cases of overcrowding are extremely lethal to children because they can dehydrate extremely quickly.

So this is one of the top concerns.

Children are not getting their typical vaccines at this point.

As you can imagine, the typical functioning of a health system is not happening.

So we will potentially, as we did in Syria, start seeing outbreaks of polio and perhaps start seeing outbreaks of measles and other ailments that we should not see in 2024.

>>That are entirely preventable.

>>Entirely preventable, Exactly.

We can't even begin to quantify how the malnutrition will affect these children as they grow up.

You know, children that are lucky these days will maybe get some bread, some cheese, maybe some fresh fruit a couple of times a week, if that.

A lot of canned food is what's being eaten right now.

It's devastating.

And I also, you know, as much as we focus on the physical ailments, you know, my children get scared in a thunderstorm.

Right.

I can't imagine for these children hearing airstrikes every night, for those who have survived, hearing airstrikes every night, undoubtedly almost all of them have lost someone, if not an immediate family member, a cousin, a neighbor, someone.

And this is not a situation where you can calm your child and tell them we'll be okay.

>>Right.

>>They may not.

You know, and the mental trauma of this is going to affect these children for the rest of their lives.

>>You mentioned, you know, this is not obvious.

This is the most widespread incursion and the deepest and most concentrated.

But this has happened four other times since 2007.

What were the mental health issues related after those incursions?

>>Right.

That's a great question.

So a studies from Gaza have shown and as to be completely expected, very high rates of depression, anxiety and what we term post-traumatic stress disorder.

Now, I say what we termed simply because some argue that in the situation of Gaza, there's no post-trauma.

The trauma is ongoing.

And it's really an understand double reaction to extreme circumstances.

Right.

We would expect that it's not a mental flaw within a person to have distress when living in these conditions.

So, you know, there are studies that show significant percentages of people with what we would diagnose medically as PTSD, but is probably something deeper and more traumatic than that.

Palestinian researchers have tried to call this even feeling mentally broken or destroyed.

Obviously, there's very few mental health services, even in the most developed of countries, let alone in a place like Gaza.

But again, going back to your earlier point, at this point, mental health services and people in Gaza are trying to do paint classes for children and trying to keep their spirits up.

But this is also just a Band-Aid.

There's only so much cheering up you can do of someone who has lived through at this point, three, four or five wars.

If you're a 15 year old, 16 year old child living in a constant situation of deprivation.

In 2020, the United Nations called an alarm because of an increased suicide rate in the Gaza Strip that they pinned to the lack of economic opportunity, the blockade, the lack of ability to live a normal life.

So we know the burden is extremely high and probably higher when we consider the forms of mental illness that we can measure.

>>Obviously, you're studying Gaza as it goes forward, but you also you have a book that's going to be published up, which is sadly related to exactly what you're seeing now.

Tell us a little about the book.

And I know it's published here later this year.

>>Yeah, actually, later, Yes.

In 2024.

It's called "How War Kills."

I make really three arguments in the book or try to make three broad themes.

And one is kind of doing what we just did.

So looking at situations in war torn countries and what are both the direct forms of violence that harm people?

Airstrikes, raids, bombs, etc..

But the second point I really try to emphasize in the book is the indirect forms of violence, starvation, infectious disease, etc..

However, I think how this book differs from other books on humanitarian health is that it also points to the health effects for all of us, and that includes us living in wealthy developed countries that don't experience war on our soil because of the culture of militarism that we all live in and the prioritization of national security, which is usually defined as military prowess, as opposed to other forms of human security, like food security, water security, environmental security, and how this kind of how war is an ecosystem that damages the health of everyone.

And so that's really what I'm trying to make the argument in the book, because I think people really do recognize, especially as now wars are increasingly on social media.

People can see images and pictures for themselves of what the destruction looks like.

What we don't often consider is what are we losing?

And by we, I mean those of us living in the US, Europe, other developed countries.

What are we losing by having such an emphasis on war making that I think many would agree, especially since 2000 has simply caused more destabilization, has caused, you know, a civilian death toll across the world that is very significant, that contributes to regional destabilization, while at the same time many social issues in these countries are ignored.

>>So what are some of the examples you've you've used and you use in the book?

>>So obviously in terms of of war contexts, I try to focus I do pull in historical context.

So obviously I consider how dehumanization and, you know, forms of direct and indirect violence were deployed in World War One and World War Two.

But I really try to look at contemporary conflict.

So as you can imagine, Syria features heavily in the book.

I do talk about the Palestinian territories, including the Gaza Strip.

I have a chapter on sieges and blockades.

>>Have you had to revise it several times?

>>If I could write a second edition now, let me tell you, it would be a little bit of a different book.

I look at the post-9-11 broad context, so both in Afghanistan and Iraq, and that's a really potent case where I'm not just talking about the health of Iraqis or Afghans or those who are made refugees or displaced, but how American society changed in that period.

I talk, of course, about the genocide in Rwanda.

So, you know, I talk a lot about what happened in Myanmar, what's happening in China.

So I try to bring in different sites of not just armed conflict, but forms of human deprivation and human rights violations that I think while they look different, they all kind of operate under the same structures of of war and militarism.

>>You're talking about the American reaction, we have, we have about 3 minutes left.

So we'll have to kind of keep this brief and hopefully we'll have you back to talk about the book again.

But you're talking about how it changed the whole 9/11 experience, the American reaction to it change the mindset of people.

And I know obviously there's a context of what's going on in Gaza and the bigger Israeli-Palestinian conflict that's gone on for 80 years.

But one common element, both for Americans but 9/11 is kind of feeling of victimhood, right?

Americans felt attacked and so they lashed out.

And of course, they create more victims, whether they're in Afghanistan or Iraq, etc.. Just as you know, Israelis felt victimhood after October 7th.

And you have, of course, massive victims in the Palestinian side.

That's a psychological impact on everyone.

But you're talking about consequences.

Do you look at that in the book at all?

>>Yeah, You know, and I think it's interesting to illustrate actually, the comparison between the two.

So, again, as you know, after 9/11, Barbara Lee was the one lone congressperson to vote against the Iraq war.

She simply said, I will and I won't quote her verbatim, but it's out there.

Let's just step back.

Let's just take a minute and think about what we're doing.

As as we all know, we did not you know, thousands of American troops died in the war on terror.

And that was, I think, hugely psychologically affecting to Americans.

Part of the book also talks about the whole military and veteran culture in the US as well, and their health care.

But, you know, I think it's important to recognize that what happens is how it's received and how it's reported.

And rhetoric is extremely important in how we consider these things.

You know, I think looking back, many of us say maybe we should have gone a different way after September 11th, you know, after the destabilization of what happened with Iraq and Afghanistan, how they have both turned out now.

You know, we had the Afghanistan pullout just a few years ago.

That was kind of a mess.

We need to be more conscious of decisions in the long term, you know, not making emotional political decisions.

You know, vengeance is not a foreign policy or at least it should not be.

And, you know, all civilians should be equally prioritized.

And I really think the media has a role to play here, because especially post-9-11, there was a lot of racist framing that contributed to how people in the US felt.

>>The dehumanizing factor.

>>Exactly.

And dehumanization is playing a significant role.

Also, I think, in regards to Gaza and and of course Syria and any other number of conflicts we can name.

So I think we lose humanity sometimes when we talk about these political issues that seem abstract, we forget that there are people on the other side who just like us, aspire to a regular life, a stable family, ability to go to college and work.

When we disconnect ourselves from those people.

And because we we are attacked and we are feeling understandably hurt and vulnerable and scared, I think that is the time for further introspection, because I think on all sides of all conflicts, what everyone wants is for the conflict to end, right?

We say we want peace, but we look at our actions and often they are diametrically opposed to what we would imagine peace would be.

So, you know, we've hoped at many points that there would be a turning point in how not just U.S. but foreign policy is waged in general that would prioritize humans on all sides.

And I think we have yet to see that happen, unfortunately.

>>Well, Yara Asi, thank you for joining us on the show.

Congratulations on the book.

>>Thank you David.

>>It's very important and very important work you continue to do to monitor these these very difficult issues that you're tracking, but obviously critically important to the people on the ground.

So.

>>Thank you, David.

Thanks for inviting me.

>>And thank you for joining us.

We'll see you again next week on another episode of Global Perspectives.