Since 30 March 2018, thousands of Palestinians have been participating in the weekly “Great March of Return” (GMR) demonstrations near the perimeter fence between the Gaza Strip and Israel, calling for the Palestinian right of return and the ending of the Israeli blockade. The demonstrations were originally scheduled to last up to 15 May, coinciding with the 70th anniversary of what Palestinians refer to as the 1948 Nakba, but have continued on a weekly basis, and also now include occasional demonstrations on the beach next to the perimeter fence in northern Gaza, in addition to night activities near the fence. Protection Cluster partners have repeatedly indicated that under international law, all Palestinians, including children, have the right to freedom of expression and demonstration.
While the majority of protestors have been peaceful, some have approached the fence and attempted to damage it, burned tires, thrown stones and Molotov cocktails towards Israeli forces and flown incendiary kites and balloons into Israeli territory, resulting in damage to agricultural land and nature reserves inside Israel. Some incidents of shooting and throwing of explosive devices in proximity to demonstrations have also been reported. Israeli forces have deployed snipers and responded with firearms, rubber bullets and tear gas canisters, some of them dropped from drones.
Between 30 March 2018 and 22 March 2019, 195 Palestinians, including 41 children, were killed by Israeli forces in the “Great March of Return” demonstrations, including during the weekly protests near the perimeter fence, protests against the naval blockade at the beach, and the night activities near the perimeter fence. 28,939 Palestinians were injured, including 25 per cent wounded by live ammunition in these GMR demonstrations. There was one Israeli force fatality and six Israeli force injuries as a result of the demonstrations: outside the GMR demonstrations, one Israeli soldier was killed and another 50 Israelis (three soldiers and 47 civilians) were reported injured by Palestinian armed groups in separate incidents, including rockets fired at southern Israel. In the same period, another 76 Palestinian fatalities resulted from other circumstance, including airstrikes, tank shelling, the opening of fire in the Access Restricted Areas on land and at sea, incidents of attempting to infiltrate into Israel, incursions and land levelling activities. (OCHA Protection of Civilians database). For a comprehensive overview of all Gaza Strip casualties see here.
Israel’s response to the demonstrations has raised serious concerns in the international community about the degree of force employed by its security forces. The large number of casualties among unarmed Palestinian protestors and notably among children - in particular the high number injured by live ammunition - in circumstances that did not appear to constitute an imminent threat of death or serious injury to Israeli soldiers behind the fence, has raised concerns about excessive use of force, by Israeli forces and the lack of protection, especially of children. The Israeli authorities have stated that they are reviewing many of the fatalities and announced the opening of criminal investigations into 11 of the deaths.
“Israeli security forces have the responsibility to exercise restraint and lethal force must be used only when strictly unavoidable in order to protect life. Force must not be used against medical personnel exclusively carrying out their medical duties. Children should never be the target of violence and Hamas and other militant groups have an obligation to protect children, ensuring that they never be put in harm’s way…The organizers of the demonstrations must ensure that protests remain peaceful.”
UN Secretary General António Guterres
On 28 February, the independent and international Commission of Inquiry into the protests in oPt, appointed by the United Nations Human Rights Council, released its initial report, which was followed by its final report on 18 March. The commission investigated all demonstration-related fatalities between 30 March 2018 and 31 December 2018 (189 Palestinian fatalities) and tracked more than 700 injuries caused by Israeli forces during the protests. With the exception of two cases, the Commission found reasonable grounds to believe that the use of live ammunition by Israeli forces against protestors was unlawful. The Commission further called on Israel to conduct thorough investigations into the killing of Palestinian civilians in the context of the demonstrations, as violations of international human rights and humanitarian law have occurred. The Israeli government has rejected the findings of the report as biased and failing to consider the threat posed by violent acts from Gaza.
In response, humanitarian actors have prioritized the delivery of immediate life-saving healthcare; the provision of mental health and psychological support for people injured or otherwise affected; and the monitoring and documenting of possible protection violations. These have included the coordination and support for forward trauma treatment points, deployment of surgical teams, special shipments of medicines and medical supplies and the allocation of funds through the Humanitarian Fund and the Central Emergency Response Fund. Despite significant assistance provided, addressing the multiple needs of the mass influx of casualties remains challenging, due to the lack of funds, years of Israeli blockade, the internal Palestinian political divide and a chronic energy crisis. In particular, Gaza’s already overstretched health sector has been struggling to cope with the mass influx of casualties.
The high number of trauma injuries during the “Great March of Return” demonstrations has impacted the capacity of the wider health sector to deliver essential services, resulting in the suspension of elective surgeries, reallocation of hospital beds to serve surgical patients, diversion of health staff and ambulances, and a strain on even auxiliary health services such as laundry and hospital cleaning. Trauma injuries and exposure to violence have increased the need for physical and mental health rehabilitation services. There are significant operational challenges to delivering immediate care to those injured, including limited essential supplies and ineffective communications, with outdated communications technology for providers, as well as lack of mobile phone coverage close to the Gaza fence.
Despite the significant risks of their work, health workers lack basic personal protective equipment such as helmets, bullet proof vests and masks to prevent gas inhalation. From 30 March 2018 to 28 February 2019, three health workers were killed and 633 injured in 420 recorded incidents against health staff and facilities. Some 98 ambulances were damaged, in addition to five other forms of health transport and three health facilities. On 19 August, World Humanitarian Day, the Humanitarian Coordinator for the oPt, Jamie McGoldrick, paid tribute to the health workers of Gaza, who “have exerted heroic efforts to treat people injured during demonstrations.”
World Health Organization case study
Rami has been injured three times during his volunteering as a first responder since the start of demonstrations on 30 March 2018. On one of these occasions, he was shot with live ammunition during an incident where his colleague Razan was killed. They were working together as part of a team of five.
“When we got close to some of those injured near the fence, the soldiers started firing at us with live bullets and gas. We retreated away from the fence and Rasha and Razan [two members of the team] fainted at that time from gas inhalation. Later, we stood away from the fence and Rasha suddenly noticed the soldiers had their weapons pointed at us. I moved just in time – I was shot in my left thigh and had a shrapnel wound in my right thigh and right hand, but it could have been a lot worse. Razan was shot in the chest. I didn’t see her after that because I was being treated, but I was told that she died half an hour later.
“We know the risks we face, but we also believe in the importance of our work and the need to provide good care for those who are injured. Still, nothing can prepare you for the psychological pain of losing a colleague and a friend like Razan. She was in such high spirits when she arrived to work on the day she died.”
Rami continues to volunteer and provide care to those injured during the demonstrations every Friday, while working as a mental health support worker for PMRS in the week.
“We have all suffered but our work is bigger than our wounds. I went straight back the Friday after I was injured. I wasn’t able to work, but I wanted to show solidarity with my colleagues and to be with them after we lost Razan. We will keep coming to help as long as there are people who need us.”
Many of the injured suffered extensive bone and tissue damage from gunshot wounds, requiring very complex surgeries. Between 30 March 2018 and 28 February 2019, 120 amputations took place as the result of injuries sustained during demonstrations, including 21 children, with 22 people paralyzed due to spinal cord injuries and nine people suffering permanent sight loss. The Health Cluster estimated that by the end of 2018, over 1,200 patients with limb injuries would require complex and timely limb reconstructive surgery; these are highly complex injuries that, if not treated, may heighten the risk of secondary amputations.
These challenges come on top of existing, systemic challenges to Gaza’s health sector in the context of more than eleven years of blockade. Since 2006-7, there has been a reduction in human resources for health, per head of the population; long-term shortages and depletion of essential medicines and medical supplies; and electricity shortages and power fluctuations causing dependence on emergency fuel for generators and resulting in damage and the reduced lifespan of sensitive hospital equipment. Since mid-2017, in the context of the intra-Palestinian divide between the Ramallah and Gaza authorities, medicines and other medical supplies, salaries for medical staff, funds for auxiliary medical services such as sterilization at hospitals, delays in countersigning of referrals, and fuel for energy that supports critical health facilities have been reduced, which has hampered the ability of the health system in Gaza to adequately respond to needs.
A lack of specialized hospital services in Gaza and the historic reliance on referrals to hospitals in the West Bank, including East Jerusalem, and Israel drives the need for patients to access health care outside the Gaza Strip. Patients requiring Israeli permits to exit Gaza for health care have faced substantial barriers to access in recent years, with the approval rate for patient permits declining from more than 90 per cent in 2012 to 54 per cent in 2017 and 61 per cent in 2018. Patients injured during the “Great March of Return” demonstrations have faced even greater barriers to accessing health care outside Gaza, with less than a fifth (18 per cent) of the 499 applications to exit from 30 March 2018 to 28 February 2019 approved. This has only been partly alleviated by the re-opening of the Egyptian-controlled Rafah Crossing almost continuously since May, as passengers are subject to unclear selection criteria, challenging crossing procedures and long delays.
Health cluster partners have supported the health sector response through continued provision of primary health care and hospital services, including deployment of specialist surgeons for trauma, orthopaedics and plastic surgery; provision and strengthening of care at trauma stabilization points; procurement of essential medical supplies; and provision and strengthening of mental health and rehabilitation services.
World Health Organization case study
Rami, 40, sits in the hospital bed stretching his right leg with a piece of white fabric to avoid stiffness in the joints. He cannot walk. He has a severely comminuted right femur fracture caused by the gunshot injury he received in October, during the mass demonstrations. Rami’s leg is temporarily stabilized with an external fixator. But to stimulate bone growth and avoid long-term disability he needs a circular frame that is currently unavailable in Gaza. Due to the chronic shortage of medicines and medical equipment, even the largest Gaza hospital, Shifa, cannot provide Rami and many other patients with much-needed health services.
Confined to bed, Rami has been waiting for treatment for over a month now. A father of six, he is almost crying: “My leg is not fixed well, and I can feel it’s moving. I need a proper fixator for my leg to heal. If I am disabled, I won’t be able to support my family.”
“If we do not receive a circular external fixator for Rami as soon as possible we will offer him a referral for treatment outside Gaza,” says Dr. Mahmoud Matar, an orthopedic surgeon at Shifa hospital. But to receive health care abroad, Palestinians must apply for Israeli permits. The approval rate for those injured in demonstrations near the fence is significantly lower than the overall approval rate for patients.
Another option for Rami is to go through a complex surgery in Gaza, but it can result in deformity, limping and persistent pain.
“Do you know what is the hardest feeling for me as a doctor?” Dr. Matar says. “To be unable to serve the patients. It is an internal disaster. Every time I can’t provide needed care for my patients, I feel like a criminal.”
Palestinians in Gaza already experience high levels of psychological distress in the context of an increasingly destabilized economy and weakened social fabric. Families’ resilience capacities are increasingly eroded, forcing households to adapt negative coping mechanisms and generating complex protection threats for individuals and households, including disproportionate impact on women, youth and children across Gaza. Children in particular are coping negatively and resorting to harmful practices: boys dropping out of schools and involved in child labour, while there are still high levels of adolescent girl child marriage. Children in Gaza are also affected by other forms of violence both in the public and private spheres. Many children with disabilities are also isolated and unable to access services such as education.
The demonstrations have also resulted in a shift in humanitarian needs to ensure capacities to accurately document cases of human rights violations, provide legal aid for injured persons seeking medical treatment outside Gaza, as well as to provide structured psychosocial support interventions and protection responses and case management to respond to the critical needs of injured persons and their caregivers. This has culminated in a significant gap in the provision of MHPSS essential services required to support affected populations to come to terms with the traumatic events experienced, and to prevent longer-term mental illness.
In response to the substantial mental health and psychosocial support needs in Gaza, the Ministry of Health (MoH), with support from WHO, established six mental health emergency teams (MHETs) to provide care to those wounded in the “Great March of Return” demonstrations. Each team consists of a psychiatrist, psychologist, social worker, mental health nurse and volunteers. Since March 2018, over 6,000 people received mental health and psychosocial support through this project.
Every Saturday, the MHETs visit trauma patients admitted to the emergency and surgical departments of the Ministry of Health (MoH) hospitals throughout Gaza. During the first visit, patients are provided with psychological first aid (PFA) and an initial assessment, during which the number of visits and types of interventions required is determined. If an injured patient is discharged from the hospital early due to lack of bed capacity, the MHETs can conduct home visits to complete the needed interventions, in particular for those who are not able to come to community mental health centres (CMHCs) due to their condition. If a patient stays in the hospital for a longer period, the MHETs will reassess their status during the second visit to determine the required interventions. In addition, the MHETs provide psychosocial support (PSS) services for the family members of those injured during home visits, if needed.
The Humanitarian Response Plan estimated that 323,000 children in Gaza are in need of protection interventions in 2019, including psychosocial support interventions. As a result of the “Great March of Return” demonstrations, it is estimated that an additional 10,420 people will have severe mental health problems and 41,678 people will have mild to moderate problems requiring MHPSS. Of this, the total number of children in need of MHPSS was projected at 26,049 children at the end of 2018. These numbers are expected to grow however, due to the medical phenomena of the manifestation of mental health incidents occurring sometime after the events.
Protection interventions have included efforts to identify and refer children affected by the “Great March of Return” demonstrations to service providers, and to strengthen community level availability of child protection and MHPSS services. The identification and referral is carried out by field-level protection focal points, one per governorate, as part of the protection emergency preparedness mechanism, who have been visiting injured children to assess their situation and to provide them with psychological first aid (PFA). Following field level child needs assessments, children have been referred to services, including case management and psychosocial support services. Ten Family Centres, through 30 outreach sites, have also provided children with access to child protection services.
As of end February 2019, UNICEF and CP/MHPSS working group members reached 2,186 injured children out of the 2,986 hospitalized due to injuries during the GMR with Child Protection and Psychosocial Support Services. Of these, 266 were referred for specialised case management services and 1,406 for structured psychosocial support services, while 36 were referred for specialised mental health services.
Additionally, awareness of and access to MHPSS services improved with ten thousand flyers for caregivers, detailing the different services each partner is providing, distributed to all six main hospitals in Gaza. Furthermore, UNICEF, in partnership with UNRWA, reached more than 21,000 children with structured recreational, mental health and psychosocial support after school activities contributing to improve their well-being at a time of great stress and vulnerability.
Child protection services are heavily under-resourced and unable to meet the burgeoning needs. By end 2018, out of a cluster target of 321,159 children a total of 61,329 (20 per cent) were reached by protection partners. As a result, affected children are at risk of developing serious mental health illnesses. There is a strong need to prevent the collapse of child protection, MHPSS and GBV services in Gaza.
Existing funding allows service delivery systems, such as the Governorate focal points and family centres, to operate at only a limited capacity, as they have faced challenges in meeting salary costs, and Family Centres have not been able to scale up responses significantly. Responders are experiencing fatigue and burnout due to the heavy workload and ongoing exposure to traumatic events. All of this is taking place in the context of a shrinking of community level services provided by UNRWA, including MHPSS services, due to the Agency’s ongoing funding shortfall.
The violence and casualties during the “Great March of Return” demonstrations have had a differentiated impact on men, women, boys and girls, as revealed by a rapid assessment carried out by UNFPA (United Nations Population Fund). Despite the relative low proportion of female casualties, the consequences of such an event are often more severe for women, particularly when the injured female is a mother, due to various social and cultural norms. The enormous number of protestors injured, compounded by the shortage of electricity, drugs and equipment, has forced hospitals to prematurely release patients, putting additional pressure on female family members who are primarily responsible for the treatment of house-bound family members. Mothers with injured children (around 15.6 per cent of the total hospitalized injured) have reported increased gender-based violence, especially psychological/emotional violence, as mothers were often blamed by their families for ‘allowing’ their children to participate in the demonstrations.
 The Israeli and Palestinian authorities are required to respect, protect and fulfil freedom of assembly and expression for all Palestinian. International Covenant on Civil and Political Rights (ICCPR) Articles 19 and 21, and the Convention on the Rights of the Child (CRC) Articles 13-15
 To date, (8,648 acres of land have been damaged by the fires. The loss to the farmers is estimated at 35 million shekels (about $10 million). According to the Israeli authorities, the “Great Return March” has been planned and led by Hamas, with “Hamas activists and gunmen hiding behind women and children as they try to breach the fence. Israeli soldiers stationed at the border have been using anti-riot measures and have been forced to use live fire to prevent the rioters from violently breaking into Israeli territory and harming Israeli civilians.” Ibid.
 From the very beginning of these events, the United Nations Secretary-General and the Special Coordinator for the Middle East Peace Process have called on Israeli forces to exercise maximum restraint in the use of live fire; on Hamas and the leaders of the demonstrations to prevent all violent actions and provocations; and on all sides to show the utmost restraint to avoid further loss of life, including ensuring that all civilians and particularly children are not put in harm’s way. The Secretary-General also called for an independent and transparent investigation by the Israeli authorities into these incidents.
 Humanitarian agencies in the oPt have called on all actors to ensure that children are never the target of violence, and must not be put at risk of violence or encouraged to participate in violence. See for example: Statement by the Humanitarian Coordinator in the oPt, 29 September 2018. Also: Joint press statement from the Humanitarian Coordinator in the oPt, the Head of OHCHR in oPt and the UNICEF Special Representative in State of Palestine, 1 August 2018. The DERC/ASG for Humanitarian Affairs also stressed in her briefing to the Security Council on 20 February 2019 that “great effort must be made to spare children from violence. They should never be put in harm’s way.”
 Implementation of Security Council resolution 2334 (2016) Report of the Secretary-General [15 December 2018 – 15 March 2019], S/2019/251 of 20 March 2019
 Additionally, 731 children were referred to medical service providers, 130 received food and cash assistance, 103 were referred to physiotherapy services, 63 were referred to rehabilitation services providers to receive assistive devices, 20 were referred to speech therapy services, 11 were linked with educational centres to receive remedial/catch-up classes and 27 were linked to vocational training centres.