People are very worried about their future. They are feeling the weight of uncertainty and fear of tomorrow. A patient said to me, "It's like walking with a stick in your shoe."

Emerging management problems in the health-care system

I met with the directors of several hospitals and observed a real need for medical supplies. Throughout the crises — Israeli army offensives, renewed tensions and blockades — the Palestinian health-care system has always managed to adapt.

Today, though, it is lacking certain basic items like atropine and adrenalin — which are needed for heart resuscitation — basic supplies like plaster casting material for broken bones as well as more expensive and complicated medicines like treatments for hepatitis C. Health care staff also no longer receive regular salaries.

These management problems will have long-term impacts. Since the beginning of the year, the Health Ministry has taken on between $3 and $8 million in debt to its suppliers, who now insist that those bills be paid before accepting any new orders. The European Union's decision triggered a crisis of confidence regarding Palestinian payments, so these same suppliers must also make immediate payment on their own orders from India, Egypt and elsewhere.

This produces a domino effect on the entire supply chain, which already operates on a "just-in-time" basis. When the Karni transit point closed at the beginning of the year, the situation worsened. Medicines — including from MSF — are blocked.

Tightening up

When you know that you won't have enough supplies to make it to the end of the month, you tighten up. In Gaza, only emergency surgeries are performed. Medicines are also prescribed in smaller quantities and patients are sent to private pharmacies, which face shortages, too.

Given the standard of living, patients cannot afford to pay for treatment. Some go to Egypt, where medicine is cheaper, but if they bring back more than a small amount, everything will be confiscated at customs. Last summer, in anticipation of possible blockages during the dismantling of the Gaza settlements, MSF stocked up on supplies and medicines, which have since allowed us to make some small donations.

During my visit, we made contributions to the general public hospital and the pediatric hospital in Gaza, as well as to the Khan Younis hospital. We will continue to do that on occasion, but the needs are very great.

The situation could quickly turn critical

If we get to the point where supplies of certain products are exhausted, treatment will stop. Managing a hospital is much more complex than simply buying medicine and paying salaries. You also have to dispose of wastes, clean and sterilize, and pay the electricity bills.

The quality of care will be affected and contamination risks will increase. Similarly, if health care providers are not paid, their motivation can suffer. Doctors working for the public health system already hold down multiple jobs so that they can achieve a reasonable standard of living.

Without salaries and supplies to carry out their job properly, you can imagine that they will only work in private offices and clinics. But people cannot — and will be increasingly unable to — pay for care. Finally, major illnesses like cancer, genetic problems and congenital deformities that, until now, have been treated in neighboring countries (Jordan, Israel and Egypt) will no longer be treated because of lack of resources.

People are very worried about their future. They are feeling the weight of uncertainty and fear of tomorrow. A patient said to me, "It's like walking with a stick in your shoe."

Uncertainty in the food supply

Several factors suggest that the food situation may worsen. Most of the birds with avian flu in the Palestinian Territories have been in Gaza. Poultry farms are failing, no one is selling any more poultry and the refrigerated cases are empty. Fish is too expensive to buy and too expensive to catch, as well. Most Gaza fishermen have lost their boats, either to confiscation or bombings. It's the same story for beef.

The largest meat supplier in the Gaza Strip imports live animals. They are blocked at Karni and the supplier has to rent pasture land in Israel to keep them alive while he waits. His livestock operations are located in the north, where Israeli Army bombings are particularly intense. He lost 45 cows in two weeks.

There are still vegetables and citrus fruits. The surplus was sold in Israel but is now rotting in Karni. The two key mills that supplied the population with bread are also subject to uncertainties at transit points. When flour is blocked, sporadic crises and riots can result, as was the case in late April. Children have become used to not eating meat or protein any more. We know the long-term risks of a poorly-balanced diet — deficiencies and the appearance of certain diseases like diabetes.

Reevaluating MSF's program

MSF teams provide psychological care, along with medical and social services, to families exposed to violence and the impacts of the occupation. Some of our patients still need this help. People who were living near the settlements, where they experienced ongoing confrontation and stress, are still subject to distress, despite the departure of the settlers.

There are also people in the northern Gaza Strip who have been living under permanent bombing since the beginning of the year, which has intensified since April to 100-300 strikes per day. They live like recluses and don't even dare trying to go to health-care facilities. Their fear is real. Shells fall on their homes. One man told us that he was shot at from a tower as he was taking his wife, about to give birth, to the hospital. People feel like they are living in an open-air prison.

We expect to continue contributing supplies and medicines and providing support to the surgery, dialysis, and pediatric departments, where the demand and needs are great and specialists are lacking. We will also continue to monitor the nutritional situation and remain on alert there.

Finally, our teams will be strengthened. Recruiting Palestinian staff will be the best way to continue our activities, especially if it becomes necessary to evacuate international staff. But that's a drop in the bucket. We cannot replace an entire health-care system and meet all the medical needs.

Since 2000, and the recent worsening of security conditions [due to violence among various Palestinian factions and violence directed at westerners, including kidnappings, by Palestinian armed groups], there have been fewer and fewer foreigners in Gaza.

Currently, MSF is one of the last aid group — along with U.N. agencies whose presence has dropped from 80 foreigners in 2005 to only 12 this year — in Gaza. Many organizations have had to halt their programs and suspend their activities. The situation in the West Bank is no better. The main refugee camp in Nablus is a regular target of incursions. In Hebron, Palestinians are prohibited from traveling on the major roads that run along the settlements, hampering supply operations and access to health care.