A right to health denied: access to oral healthcare during the war on the Gaza Strip

Summary.

• Since October 7 2023, attacks on healthcare facilities, healthcare providers, and universities alongside restricted aid entry by the Israeli military has significantly obstructed the ability to provide oral health services in the Gaza Strip.

• In addition to allowing unimpeded immediate humanitarian access to address the current needs of Palestinians, the impact of the oral health crisis in Gaza extends beyond the immediate conflict and thus necessitates sustainable interventions that address both the structural and social determinants of Palestinian health.

Amid global conflicts, access to oral health—a vital aspect of well-being—is often overlooked as a critical health priority. Prior to 7 October 2023, Palestinians in the Gaza Strip faced limited access to oral healthcare due to a limited and suboptimal public oral health system and a de-developed economy caused by a 17-year siege, severely limiting the ability to access public and private oral health services.¹ The onslaught in Gaza, marked by attacks on healthcare facilities, personnel and civilian infrastructure, alongside restricted aid entry, has intensified human suffering and has made it almost impossible to access oral health services.²

Primary healthcare in Gaza, including oral health services, is provided through four main bodies: the Ministry of Health (MoH), UN Relief and Works Agency (UNRWA), International non-governmental organisations and the private sector.¹ The MoH in Gaza previously had 25 operational dental clinics, serving mainly Palestinians who did not have registered refugee status with UNRWA, with an average capacity of 32 patients/day per clinic. At the time of writing, after 9 months of war on the Gaza Strip, only five MoH dental clinics are operational (zero in Rafah, two in the Middle areas, one in Khan Younis and two in North Gaza), with an average capacity of 70–80 patients/day per clinic. The remaining MoH dental clinics have been either destroyed, severely damaged or rendered non-functional.² Similarly, UNRWA operates a network of primary care facilities that are a lifeline for many in Gaza.³ Before the war, UNRWA had 24 dental clinics, serving 1.3 million Palestine refugees, with a capacity of 58 patients/day per clinic.³ As of July 2024, only four UNRWA dental clinics remain functional, some operating double shifts and serving 90 patients/day per clinic to manage the high influx of patients.³

University dental clinics, which had previously provided crucial support to the four main public oral healthcare providers, have also suffered immensely during the war. Israel’s destruction of all higher educational institutions has not only deprived tens of thousands of Palestinians of their right to education but has also deprived thousands more of their right to oral healthcare services.^{4 5} Before the war, Al-Azhar University and the University of Palestine—Gaza’s only universities offering dentistry degrees—operated a total of 156 dental units, providing daily services for approximately 500 patients and graduating 300–400 new dentists annually. The war has also taken a devastating toll on Gaza’s oral healthcare providers, with at least 48 dentists, 26 dental students and 2 university staff killed as of July 2024.⁶

Displacement has also severely impacted the ability to access oral healthcare. Continuous bombardments and evacuation orders have left nearly 90% of the 2.3 million population displaced, with some families displaced up to 10 times.² As of early July 2024, over 930 000 people were estimated to reside or be displaced in Khan Younis—a city with only one MoH dental clinic, two UNRWA dental clinics and approximately 15–20 semifunctional private clinics that remain operational. This amounts to roughly 3 dental clinics per 100 000 residents, not accounting for the inability of the majority of the population to afford private dental care. Moreover, the ongoing insecurity and the risk of being targeted on the way to health clinics have also deterred both patients and healthcare workers from safely accessing the limited dental facilities that remain operational, further disrupting critical healthcare access for the people of Gaza.

From 7 October 2023 to 22 July 2024, only 2445 trucks carrying medical supplies were allowed to enter Gaza, accounting for just 8.5% of all incoming trucks.⁷ Deliveries of dental supplies were nearly non-existent,⁸ causing prices of dental materials to increase up to 10-fold. Unable to afford the soaring material costs, dentists are increasingly relying on basic techniques and materials to treat their patients, many operating in tents with minimal resources. The fear of undergoing procedures without adequate pain management has also deterred many Gazans from seeking dental healthcare services. Even when dental clinics have the necessary materials to provide advanced treatments like root canals or prosthetics, the ongoing displacement of residents and relentless bombing make it extremely difficult for clinics to operate consistently and for patients to attend crucial follow-up appointments. This ongoing vicious cycle has left dentists with limited options beyond the last-resort treatment, such as tooth extraction.

The psychological trauma of living in constant conflict in Gaza has severely impacted peoples’ oral health, especially among children and adolescents. Even before the ongoing war, over half of Gazan children suffered from post-traumatic stress disorder.⁹ Depression, anxiety and other mental health issues stemming from sustained and ongoing trauma have led to neglected oral hygiene routines, as people lack the motivation to regularly brush, floss and visit the dentist.^{10 11} This situation is further compounded by widespread acute malnutrition caused by restrictions on aid delivery to Gaza,¹² leading to vitamin deficiencies like scurvy, which result in gingivitis, bleeding gums and other dental problems.¹³ From the oral health provider perspective, the ever-increasing workload leading to burnout, personal suffering and malnutrition has inevitably compromised the mental health of oral health providers.

The impact of war extends the oral health crisis in Gaza beyond the immediate conflict and thus necessitates sustainable interventions that address both the structural and social determinants of health and the immediate and long-term effects of war.^{14 15} According to the World Dental Federation’s (FDI) policy brief,¹⁶ neglecting oral health during crises not only worsens physical health but also strains healthcare systems, increases the need for emergency treatments and hinders recovery and integration. Strategic collaboration and the integration of oral healthcare into primary health frameworks are essential to ensure comprehensive care for displaced and affected populations. We support the FDI’s initiative to include oral health in primary care packages,¹⁷ and echo calls¹⁸ for humanitarian organisations to prioritise oral healthcare in crisis response efforts for Gaza. Yet, without a permanent ceasefire, an end to the siege and a commitment to rebuilding a sovereign healthcare system in Palestine, Palestinians will remain vulnerable to higher oral disease prevalence, affecting all aspects of physical and mental health.

The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or UKHSA.

Data availability statement

No data are available.