Although the problems facing the Palestinian health sector in Gaza are even more serious today, after violence peaked a year ago, they problems were ongoing and pre-dated this episode of extreme violence.

The quality of health services, already fragile, continues to decline

The health care system's ability to function properly has been weakened considerably. Most medical equipment is unreliable and the embargo makes it impossible to obtain certain spare parts. Similarly, medical units also face drug shortages. More than 5,000 people were wounded during the January war. Many are disabled and the only rehabilitation center in the Gaza Strip also finds it difficult to import raw materials and the components required to manufacture artificial limbs.

The waiting time for a prosthetic now extends to mid-2010. Even as the 150 disabled patients await theirs, unexploded munitions continue to kill and wound "Two children have been killed and at least three wounded while playing with these weapons," says Jean-Luc Lambert, MSF head of mission. "One year later, the children of Gaza are still losing their lives to the war."

Individuals who were disfigured and/or burned should be able to obtain plastic surgery and post-operative care. However, Gaza's only plastic surgeon struggles to treat them all, even as domestic accidents - such as exploding gas bottles - and inter-Palestinian clashes produce their own victims. It is estimated that 40 percent of patients with a chronic illness could not obtain their medical treatment during the January offensive (life-threatening emergencies received priority at that time).

This has had a long-term impact on their health. "Chemotherapy, which often combines three drugs although only two are available in Gaza, is partially available," Lambert says. "And while 30% of the cancers in Gaza are breast cancers, we cannot import the chemical used for the X-rays required for mammography." Patients who cannot be treated in the Gaza Strip should be cared for outside the Occupied Territory, but requests for authorization to travel are so complicated to obtain - on both the Israeli and Palestinian sides - that some cannot leave Gaza in time to arrive for their appointment.

The psychological impact of Operation Cast Lead is difficult to assess

"The psychological impact of Operation Cast Lead is difficult to assess. MSF's team of psychologists must respond to a surge of requests. The waiting list is long." Children are particularly affected (school absenteeism and failure, aggression and bedwetting). Domestic violence has become a major social problem. "During the war, the lack of safe shelter providing protection against almost non-stop bombing and the continued sealing of the borders have trapped the civilian population, placing people in a very vulnerable position. They have lost all sense of security, which is fundamental to general psychological well-being." The World Health Organization estimates that between 20,000 and 50,000 people will have long-term illness following the offensive.

An economic slump

Livelihoods were systematically destroyed, particularly in January. Many small companies, both factories and shops, and private homes were razed or seriously damaged. The United Nations estimates the total cost of this destruction at $139 million. Today, 140,000 Gazans are unemployed, bringing the unemployment level to 50 percent, compared to 32 percent in 2007. "These figures are among the highest in the world. The blockade has caused the loss of 120,000 jobs in the private sector.

On average, every worker must support six or seven family members. Seventy percent of families live on less than $1/day. Today, 75 percent of the Gaza population - more than 1.1 million people - relies on food aid." The restrictions related to heightened security, the last military offensive and the increasingly drastic limitations on fishing and farming areas affect food supplies and produce major price fluctuations.

In January 2007, more than 600 trucks entered Gaza every day, compared to fewer than 100 today, 70 percent of which carry food stuffs. Last, as winter approaches, restrictions on importing construction materials will worsen the already-precarious living conditions for the 20,000 displaced persons. One year later, most of them still live in makeshift shelters or the ruins of their house.

Electricity, water and sanitation shortages

During Operation Cast Lead, crucial electricity and water infrastructure and the sanitation system, were targeted and partially destroyed. "There's just one power plant left in Gaza. Sixty percent of energy needs are met by buying electricity from Israel and Egypt. Power outages - which last from four to eight hours - occur every day and 10 percent of the population has no electricity at all. The water system is also extremely fragile and 90 percent of the water provided to Gaza residents fails to meet WHO safe drinking water standards.

Every day, approximately 80 million liters of wastewater go untreated and are discharged into the Mediterranean, posing risks to health and the environment - particularly fishery products. Water-related illnesses, such as acute diarrhea, are increasing. No major reconstruction or repair of this public infrastructure has been performed to date. "The blockade must be lifted today. It's urgent. Everything is lacking, including books and pencils.

Hospitals and schools have no more windows or roofs. Everything must be rebuilt - houses, health facilities, public infrastructure. Then the population will be able to rebuild itself, both physically and psychologically," Lambert concludes.