Living under blockade for 13 years has forced Palestinians in Gaza to be creative, particularly those with a training in engineering. Female entrepreneur Majd Masharawi has pioneered bricks made from coal and wood ash to reconstruct demolished buildings through her company Green Cake; her latest innovation, Sunbox produces solar electricity around the Gaza strip; and the tech ecosystem development initiative Gaza Sky Geeks provides remote work opportunities online for youth locked into the 365 square km of land. Now, engineers have been forced to confront the COVID-19 pandemic with the same ingenuity, building ventilators from scratch.

While this kind of innovation is outstanding, it is produced under coercion. The Israeli-Egyptian blockade of Gaza has included restricting and withholding the import of vital, life-saving medical equipment and supplies. According to Gaza’s Health Ministry, there are just 65 ventilators in the Gaza strip for a population of close to 2 million people. Amidst the COVID-19 pandemic, a contagious respiratory disease, this is a horrifying shortage and one that is a result of deliberate Israeli policy.

Farouq Sharaf, an electrical engineer at the Islamic University in Gaza is trying to find a temporary solution to this shortage. Alongside a team of academics at IUG, he has developed a low-budget ventilator that can be locally produced in Gaza. “I came up with this idea with a colleague teaching on our Disaster and Crisis Management programme at IUG, who has worked on the multiple conflict emergencies we have experienced here in Gaza. He asked if a small-scale ventilator, similar to one used in ambulances, could be developed quickly and at a low cost – so I gave it a try”.

Although currently this ventilator could not sustain COVID-19 patients long term, it is better than nothing. The health system in Gaza is on the brink of collapse, strangled by over a decade of blockade and Israeli military attacks. Hospitals and homes alike have limited and irregular electricity and a lack of clean water for hand washing. Israel has so far refused to send any medical supplies to the Gaza Strip to support a COVID-19 response, suggesting that allowing supplies into Gaza will be conditional on the recovery of two Israeli soldiers captured in Gaza during the war in 2014.

The ventilator being developed by Sharaf is similar to that which would be used to transfer patients between departments within the hospital, or in an ambulance, but with some modifications to allow for continuous use over a longer period. This ventilator also operates automatically instead of manually. At around $300, it is cheap to produce and is currently being tested by the Ministry of Health in Gaza. The goal is to produce 100 ventilators initially, expanding as the need in Gaza grows. A further model is under development for use in ICUs. “The problem is not with the ideas or the design – but we simply do not have access to the materials that we need to produce this here in Gaza”, Sharaf explained.

Since 21 March, Gaza has recorded 12 cases of COVID-19, out of a total 288 cases reported across the 1967 occupied Palestinian territories. The Hamas government was quick to respond to the outbreak, focussing attention on implementing a compulsory 3-week quarantine for anyone traveling into Gaza from either the Rafah or Erez crossings, converting schools and hotels into quarantine facilities, and building two new isolation wards. Public celebrations, weddings, funerals and Friday noon prayers have been suspended; and cafes and restaurants have been closed.

Although the number of confirmed cases remains low, tests conducted so far have been minimal. After the Ministry of Health recently announced they had run out of tests, the WHO announced plans to transport a further 480 tests to Gaza. Given that so many Palestinians in Gaza live in densely overcrowded refugee camps, where social distancing is impossible, the actual number is believed to be much higher.

According to the World Health Organisation the items urgently needed to address COVID-19 alongside ventilators are cardio-monitors, emergency cars and portable X-ray machines; equipment, disposables and drugs for the treatment of a respiratory disease; testing kits; and essential supplies for infection prevention and control, including PPE kits. All of these are in short supply.

While innovative engineering can provide a stop gap to this shortage temporarily, a sustainable and lasting improvement to the health outcomes of Palestinians in Gaza can only be feasible if the underlying political context is addressed.

The need to rapidly produce new products with limited material resources also raises ethical questions for engineers in Gaza. Sharaf has a small private electrical company in Gaza, but has never before developed anything in the medical field. “We have some medical equipment engineers in Gaza, but there is no industry for this work as such”, Sharaf explained.

His model is one of three currently under development in Gaza and due to be tested by Gaza’s Ministry of Health in the coming days, but there is no capacity in Gaza to test this equipment at scale. “The challenge in ventilator development is the issue of trying to standardise the device with limited materials available. The market in materials for medical engineering is extremely poor because of the blockade” said Sharaf.

Equipment like this would normally go through multiple rounds of wide-scale testing before being operationalised, but this is not an option in Gaza. Like many in his sector, Sharaf is deeply concerned that these products will be forced into use before they are technically safe. Ventilators are crucial in the response to the pandemic but the highly competitive global market and high prices make it impossible to consider importing devices to Gaza – even if such imports were permitted by the blockade.

Even amidst these concerns, basic ventilators like this one could be lifesaving.

The story of ventilator innovation in Gaza is one of historic structural violence, appearing in new guises in the context of COVID-19. In accordance with international law under the Fourth Geneva Convention, Israel as an occupying power is responsible for the population living under its control, which includes all Palestinians in the Gaza strip. The blockade on medical supplies must be immediately lifted, and Palestinians must be allowed out of Gaza if they require hospitalisation elsewhere. As things stand, the structural violence of the blockade will be a fundamental determinant of how COVID-19 will impact the Gaza Strip.