Why Gaza is the worst of war zones

Over the past 30 years I have worked in war zones around the world as a surgeon treating casualties resulting from conflict, including in Syria, Yemen, Afghanistan and Iraq. War wounds, the effects of fragments from blast injuries and gunshot wounds require a special set of skills to manage.

At times there are mass casualties, and some of the patients I have seen over more than 30 war missions had overwhelming injuries that even the best units in the world would struggle to treat. The majority of injuries, though, could be dealt with using the resources at hand. Most patients at least had a good chance of arriving at a hospital within a timeframe that allowed them to have the best surgical decision-making.

Gaza, however, is like no war zone I have ever witnessed.

During my recent month-long mission to Rafah, the approach to the city, which is at the southern end of the Gaza Strip, was marked by mile after mile of stationary trucks carrying aid which didn’t appear to be going anywhere. The drive from Rafah through to the Beach Road, where most of the NGOs were staying, was a shock to behold. I have worked in refugee camps in Syria and Bangladesh where orderly tented structures had been placed a safe distance apart, but here I witnessed thousands upon thousands of people massed in a small area. There were whole families with just a polythene sheet over their heads. The more fortunate had a tent but these might hold six or seven people including children with hardly any room to sit, never mind sleep, and with no toilet facilities. It felt inhumane. This went on for miles, with small clearings which were full of stinking and rotting rubbish infested with flies and surrounded by children.

My mission in Gaza was not to work as a surgeon on the front line, dealing with the effects of gunshot wounds and fragments from blast injuries, but to be on the second line, dealing with the surgical complications of thousands of patients. It was worse than I could have imagined.

I worked in the only functioning hospital in Rafah. It had around 40 beds and two operating theatres, but by the time I arrived, there were already over 2,000 patients lying in the wards, in corridors and in any other space that was not occupied. There were often six to eight patients in a side room meant just for one. Many patients had had operations and their risk of cross-infection, because of proximity to each other, was enormous. Many had wounds that had been stitched but fallen apart, dressed with sodden gauzes stinking of pus and bacteria. All were malnourished, further weakening their immunity and the normal healing process.

There was a total breakdown of the usual medical care that a society would give to its population. Even in the midst of vicious wars such as in Yemen or Syria, people had access to basic life-saving medicines. Not so in Gaza: all pharmacies had closed down and there were no drugs. As a result, there was no access to daily medications for people with chronic illnesses, such as diabetes, and those with cardiological, renal, oncological and haematological diseases. Of the 12 renal dialysis machines that were available in our hospital, ten had broken down and the other two could not cope with the 30-fold increase in patients requiring dialysis. There were no oral antibiotics available for common conditions like chest infections or other gastrointestinal illnesses.

Before the war, the World Health Organisation ran a mass-casualty training programme and allocated an area within the hospital for the “red” patients—who would be triaged into those requiring surgery immediately and those who could wait a while—and a separate area for the “green” patients who were the walking wounded. But by the time I arrived at the hospital this system had broken down, overwhelmed by the sheer number of ill and dying patients. The chaos I saw made a mockery of patient triage or any sense of order.

With no access to routine medical or surgical help it appeared that the hundreds of thousands of people squeezed together were on their own; it was the grimmest of tests for Darwin’s theory of survival of the fittest. The effects of communicable infectious diseases were cruelly apparent: some children could not breathe owing to the effects of simple chest infections that had progressed and turned their lungs into pools of pus, known as empyema. For the first time in my life I found myself clinically diagnosing this awful condition—something you would read about in a medical book in the 19th century—in young children. Next to one six-year-old I found half a litre of pus in the drain bottle.

I was operating on young people dying of a ruptured appendix, simply because they had not been diagnosed early enough or could not get to a hospital to see a doctor. I operated on patients with bowels that were obstructed owing to cancers that should never have progressed so far. Once removed, the cancerous bowels were simply thrown away. Patients weren’t offered the vital pathological analysis that informs their continued treatment, because there were no laboratories.

The accident and emergency department was overrun and there were patients lying on the floor and propped up against the wall. Many of them had such severe infections of their limbs that they required amputation; some were due to the effect of diabetes being left untreated, others from the effect of previous injury. Khan Younis, a city north of Rafah, was at that time under bombardment and many of the wounded had to be left for 12 hours or so before being brought in to us. The majority of them were by that time in a state where nothing could be done. They were dead by the morning.

David Nott is a consultant surgeon at St Mary’s Hospital in London, where he specialises in vascular and trauma surgery. He is the co-founder of the David Nott Foundation, which trains surgeons in war zones.

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