‘All these efforts will amount to nothing in the case of an Israeli invasion of Rafah.’

As Israel continues to threaten a full-scale assault on Rafah in southern Gaza, local, regional, and international aid groups have been scrambling to try to prepare to respond to the catastrophic humanitarian impact a ground invasion is expected to have. Facing a severe scarcity of supplies and resources, people involved in the effort say whatever preparations they can make will undoubtedly fall far short of the needs.

“We’re taking the Israel threats very seriously, and are acting accordingly,” Dr Bashar Murad, executive director of the Palestinian Red Crescent in Gaza, told The New Humanitarian. “We’ve seen what the Israeli military is capable of doing in Gaza City, in the north of Gaza, and in Khan Younis. This could all be replicated in Rafah too.”

The nearby coastal region of al-Mawasi – which Israel unilaterally declared a ‘safe zone’ earlier in the war, although it has continued to bomb and kill civilians in the area – has become a staging ground for these efforts. Hundreds of thousands of displaced people have already relocated to al-Mawasi from all over Gaza. Preparing for a new influx from Rafah, aid groups have been building new displacement camps, emergency medical clinics, food warehouses, and other humanitarian infrastructure in the area.

Israel, however, is continuing to obstruct the delivery of aid to Gaza and hamper humanitarian activities – including by killing an unprecedented number of aid workers – inside the enclave. A sparsely populated agricultural area before the war, al-Mawasi also lacks basic infrastructure, such as paved roads, water supply lines, electricity, and sanitation facilities. These limitations are making it difficult for aid groups to find suitable locations to establish facilities and enough supplies to stock them.

Still, the increasing number of medical clinics, community kitchens, aid distribution points, warehouses, and temporary field offices for local and international aid groups was clearly visible on a recent visit to al-Mawasi by The New Humanitarian. Many facilities are housed in tents and sheds, while seaside vacation homes and vegetable and poultry farms have been repurposed into aid warehouses and communal kitchens.

“All these efforts will amount to nothing in the case of an Israeli invasion of Rafah,” Dawoud al-Astal, a relief activist and supervisor at the local Al-Fajr Youth Association, which has been providing support to displaced people in al-Mawasi, told The New Humanitarian.

Much-needed humanitarian work may come to a halt altogether because it is unclear how aid will reach Gaza if the two main border crossings used to bring aid in – both in Rafah – are cut off by an invasion, the Red Crescent’s Murad added.

Fears of Rafah assault

With a population of around 275,000 before the war, Rafah is the last major urban area in Gaza that is yet to see a large-scale Israeli ground offensive. Around 1.4 million people forcibly displaced from their homes in other parts of Gaza have taken shelter in and around the city. Aid groups are expecting many of these people to flood into al-Mawasi if and when an Israeli invasion of Rafah begins.

Global leaders – including US President Joe Biden, who has been a stalwart backer of Israel’s war – have warned the Israeli military against invading Rafah, but Israeli Prime Minister Benjamin Netanyahu has vowed to push ahead, saying a ground invasion of the southern city is necessary to take down Hamas. The Palestinian political and militant group, which has governed Gaza since 2007, is responsible for launching the deadly 7 October attacks into Israel that precipitated the current war.

Six months into Israel’s military campaign, 1.1 million people are facing imminent, man-made famine in Gaza, over 34,000 have been killed, nearly two million have been forcibly displaced, and the entire population is reliant on an insufficient supply of humanitarian aid.

Israel recently pledged to increase humanitarian access after killing seven staff from the NGO World Central Kitchen in drone strikes. Whether that will happen, and how far it will go towards addressing the immense needs in Gaza, remain to be seen. Aid leaders have repeatedly said an immediate ceasefire is needed to avert further catastrophe in the enclave.

Outside of Rafah, much of the rest of Gaza has been left in ruins, and aid access is even more restricted in the north of Gaza than it is in the south. These factors would make it difficult for people fleeing an Israeli assault on Rafah to return to homes elsewhere in Gaza – many of which have been destroyed – or to seek shelter in other parts of the enclave.

‘A complete catastrophe’

Al-Mawasi – a narrow strip of territory along the sea less than one kilometre wide in some places, extending from the north of Rafah to the south of Deir al-Balah – is a last resort. One of the top priorities of aid groups has been to try to build some healthcare capacity in the area to try to compensate for the devastation of Gaza’s medical sector.

“An Israeli invasion of Rafah will result in a complete catastrophe to the healthcare system, of which only the small hospitals are operational at a capacity of 270%,” said Murad, from the Palestinian Red Crescent.

Already, 26 out of Gaza’s 36 hospitals have been knocked out of service by Israel’s military campaign. The 10 remaining hospitals (four in the north and six in the south) are only partially functional.

The Palestinian Red Crescent has opened 13 new medical clinics in al-Mawasi, Rafah, Khan Younis, and Deir al-Balah to try to supplement capacity. Mostly housed in tents and sheds, these facilities offer treatment for maladies – including the spiralling number of cases of respiratory infections and diarrhoea – as well as efforts to stabilise patients injured in airstrikes before trying to refer them to one of the few remaining hospitals.

The Palestinian Red Crescent has also set up a command centre, new warehouses, and has moved some of its ambulances to areas of al-Mawasi that Israel has designated as ‘safe’, Murad said. The group has set up a field hospital in the area and is working with the Egyptian Red Crescent to create a more advanced facility to serve al-Mawasi, Rafah, and Khan Younis, he added.

Other organisations and the Gaza Health Ministry have also set up medical tents to offer basic treatment to patients. But supplies are still limited, they do not have the capacity to handle critical injuries, and they will be quickly overwhelmed by an influx of displaced people if Rafah is invaded, people involved in the efforts said.

‘Still not enough’

The number of displaced people already in al-Mawasi is “over and above the limited resources and infrastructure the area has had since before the war”, Hany Nabil, a relief volunteer and activist from al-Mawasi, told The New Humanitarian. “This is an area that has no clean water, no infrastructure, and no necessary resources which relief work requires.”

Nabil has been working to try to provide fuel, medication, shelter, and other forms of support to people in al-Mawasi. Those supplies are located in Rafah and have to be transported to the area. An Israeli assault on the city would cut that crucial lifeline, Nabil said.

“Rafah is where the medicine and fuel warehouses and storage facilities are, and it’s where foreign medical teams arrive to support the healthcare system and where the real infrastructure is,” he explained.

Al-Astal, from al-Fajr Youth Association, said the group has been able to turn a poultry farm into a warehouse for aid supplies. Recently, they were able to use it to cook and then distribute food to hundreds of people in al-Mawasi. These efforts, however, are not enough, he added.

“If a mass displacement takes place, an immense and sophisticated level of coordination and massive resources, along with international support, will be needed and is incredibly lacking at the current stage,” he said. “We have been given no clear plan by Israel on the timing, locations, or scale of its offensive. We are working in full-swing given the little we have.”

Israel has said it will direct civilians in Rafah to ‘humanitarian islands’ ahead of its Rafah offensive. Al-Astal described this plan “an unrealistic scenario that is inapplicable on the ground due to the limited space in al-Mawasi and lack of infrastructure”.

“The exodus has not yet started, and we are struggling to find suitable venues to offer our services,” he said.

International aid groups have been similarly critical of Israel’s plan.

The number of displaced people in al-Mawasi is already multiplying, as people preemptively leave Rafah in an illusory search for safety elsewhere. The number of people registered to receive support from Al-Fajr Youth Association multiplied from around 6,000 to nearly 16,000 over a matter of days recently, according to al-Astal.

The group is distributing thousands of food parcels, vegetable baskets, milk, blankets, clothes, and diapers on a daily basis, but it “is still not enough to meet the needs of people”, he said.