Healthcare under siege: Geopolitics of medical service provision in the Gaza Strip.

Siege, a process of political domination aimed at isolating an entire population, represents a unique threat to healthcare provision. This study is a qualitative examination of the impacts of siege on the practices and systems that underlie health in Gaza. Data are from participant observation conducted over a period of six years (2009-2014), along over 20 interviews with doctors and health administrators in the Non-Governmental Organisation (NGO), Governmental, and United Nations sectors. Analyses were informed by two connected theories. First, the theory of surplus population was used, an idea that builds on Marx's conception of primitive accumulation and Harvey's accumulation by dispossession. Second, Roy's theory of de-development was used, particularly as it is connected to neoliberal trends in healthcare systems organizing and financing. Findings indicate that siege impinges on effective healthcare provision through two central, intertwined processes: withholding materials and resources and undermining healthcare at a systems level. These strains pose considerable threats to healthcare, particularly within the Ministry of Health but also within and among other entities in Gaza that deliver care. The strategies of de-development described by participants reflect the ways the population that is codified as a surplus population. Gazan society is continually divested of any of the underpinnings necessary for a well-functioning sovereign health care infrastructure. Instead of a self-governing, independent system, this analysis of health care structures in Gaza reveals a system that is continually at risk of being comprised entirely of captive consumers who are entirely dependent on Israel, international bodies, and the aid industry for goods and services. This study points to the importance of foregrounding the geopolitical context for analysis of medical service delivery within conflict settings. Findings also highlight the importance of advocating for sovereignty and self-determination as related to health systems.