Rebuilding health services in Gaza won’t be possible while Israel maintains blockade, says reportBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6644 (Published 04 November 2014) Cite this as: BMJ 2014;349:g6644
All rapid responses
Last August we published a rapid response at bmj.com to publicise the cumulatively devastating effects upon Gaza’s health system of 12 years of Israeli blockade and their strategy of de-development and impoverishment of Gazan society. Israeli restrictions have produced chronic shortages of almost all essential medicines and hospital equipment, of fuel to run hospital generators, the cancellation of all elective surgery (affecting more than 6000 people), hospital closures, and many doctors and staff on reduced or no pay. (1)
In addition, since March Israeli snipers have been firing military grade ammunition and maiming bullets (2) at the border at unarmed demonstrators, killing 257 to date (3). This week BBC Radio 4 quoted the UN for the total number wounded - more than 23,000! (4). Medicines Sans Frontieres estimates that “...a massive 3,520 people will need further surgery..”, far beyond the grossly depleted resources available...”.(3) The shooting continues: on Friday 25 January 1 person was killed, and 153 injured, including 34 children, 5 women, 1 journalist, and 5 paramedics on duty. (4) Indeed, since March, 3 clearly marked medics have been shot dead on duty, 580 medics wounded, and 94 ambulances damaged (5-7). The targeting of health workers is itself a war crime.
We write again now at a point when Gaza’s hospitals are in particular peril of total shutdown because of lack of electricity or fuel to run generators. To keep up the pressure of the siege, Israel rations the entry of fuel into Gaza, including imposing conditions on donors like Qatar. One of the hospitals that nearly shut last week was Al-Nasr Children’s hospital, which currently has 8 children in intensive care, 30 premature babies in the nursery, 100 other child inpatients, and 250 children attending the emergency department. Another, Al-Rantisi Children’s Hospital, has 45 children with renal failure, 4 children in intensive care, 10 child inpatients with cancer, 70 others needing chemotherapy,10 children with chronic lung disease, 5 with heart disease, and 10 with other diseases. A third, Al-Najjar Hospital, serves 263, 000 people, has 65 beds (including 23 child beds), has 93 patients in renal failure, should provide key laboratory services, and sees hundreds of cases in its emergency department every day. A fourth, the Eye Hospital, sees 2500 cases and performs 250 surgical procedures monthly (glaucoma, cataract, retinal surgery). 1250 patients with diabetic retinopathy, glaucoma and chronic corneal conditions are threatened by loss of sight if services stop. Also living hand to mouth is the psychiatric hospital, which currently has 29 inpatients.
This grotesque situation, a violation of the 4th Geneva Convention that guarantees unfettered access to medical facilities for conflict-affected populations, is an intended element of the siege, and persists because no one with political clout challenges Israeli impunity. A UN General Assembly resolution last year has been simply ignored. And no sanctions have been requested yet.
Gazans are turning to the solidarity of the international community and to UN for the lifting of the siege and for justice, for how long more should they wait?
(1) BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3299 (Published 13 August 2018)
(2) BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3295 (Published 13 August 2018)
Competing interests: No competing interests
I am the Head of Plastic and Reconstructive Surgery in Gaza and I am writing in follow-up of the rapid response “The Maiming Fields of Gaza” of 4 May. (1) As of 18 May, the death and injury toll, rising every day, is 117 dead, including 13 children, and no less than 12,271 injured. 6,760 have been hospitalised, including 3,598 with bullet wounds. 19 clearly identified medics have been shot to date. (2)
The humanitarian agency Medecins Sans Frontieres (MSF) has been operating in Gaza and says that people have been shot with bullets that have caused fist-sized wounds of “unusual severity”. Marie-Elisabeth Ingres, head of MSF Palestine says in their report that “half of the more than 500 patients we have admitted in our clinics have injuries where the bullet has literally destroyed tissue after having pulverised bone”. (3) This is what we are facing. I have seen a great deal of physical trauma in Gaza following Israeli attacks but have not seen these kind of injuries before. From the appearance of the wounds there appears to have been systematic use by Israeli Defence Force snipers of ammunition with an expanding ‘butterfly’ effect.
There are currently between 300 and 350 high energy compound tibial fractures in Gaza as a result of live fire. These are the most difficult of all open fractures to treat. Complex lower limb injuries of this severity may require between 5 and 7 surgical procedures, with each operation taking 3-6 hours. Even with state-of-the-art reconstruction, healing takes 1-2 years. Most of these patients will develop osteomyelitis. A steadily increasing toll of secondary amputations is inevitable. They will also need intensive rehabilitation, but the only rehabilitation hospital in Gaza was destroyed by Israeli bombing in 2014 and has not been re-built. Mass lifelong disability is now the prospect facing Gazan citizens, largely young, who were merely gathering in unarmed protest about Israeli occupation and siege that has rendered their political and social futures impossible.
To reconstruct such injuries is entirely beyond the capabilities of Gazan medical services already depleted by the 12 year Israeli siege described in the earlier rapid response. Shifa hospital is anyway swamped and there are no beds. Moreover the level of expertise required for such reconstructive surgery is beyond that generalist orthopaedic surgeons, requiring dedicated Limb Salvage Teams. I am sure that if over 6000 injured patients, more than half with bullet wounds, required admission to hospitals in London over a short period of time, your services would be stretched even though you are fully resourced. I am told that no single limb reconstruction service in the UK has ever been confronted with such mass leg casualties. How are we here in Gaza to manage this situation?
I understand there is now the question of an investigation by the International Criminal Court.
We in Gaza cannot but ask why has no European government spoken out about events which if they had happened elsewhere would surely have been called an international outrage and probable war crime?
Competing interests: No competing interests
Since 30 March 2018, Palestinians civilians living as refugees and exiles in Gaza ever since they were driven out from Palestine have been gathering in mass, unarmed demonstration about their right of return to the homeland they lost in 1948. Confronted by the Israeli army, including 100 snipers, the toll of dead and wounded Palestinian civilians is mounting at a shocking rate as we write.
There is a background to this. Firstly, there is the ongoing impact of the 12 year long Israeli blockade of Gaza on the care and health of her people, and the degrading of its health services. The violence and destruction inflicted by Israeli military action in Operation Protective Edge in 2014 and Operation Cast Lead in 2008-9 marked a distinct turning point in the pauperization of Gaza, against a backdrop of an ever tightening blockade since 2006.That assault in 2014 killed over 2,200 civilians, a quarter of whom were children, wounded 11.000, destroyed 15 hospitals, 45 clinics and 80,000 homes.(1)
Since 2014 Israel has further tightened the passage of essential medicines and equipment into Gaza, and of the entry of doctors and experts from abroad who offer technical expertise not available locally. Gazan hospitals have been depleted of antibiotics, anaesthetic agents, painkillers, other essential drugs, disposables, and fuel to run surgical theatres. (2) Patients die while waiting for permission to go for specialist treatment outside Gaza. All elective surgery has been cancelled since last January 2018, and 3 hospitals have closed because of medication, equipment and fuel shortages (3). Medical personnel have been working on reduced salaries. Gazan health professionals find it almost impossible to get Israeli permission to travel abroad to further their training.The regular episodic military assaults on Gaza and the current targeting of unarmed demonstrators are part of a pattern of periodically induced emergencies arising from Israeli policy. The cumulative effects of the impact on healthcare provision for the general population have been documented in multiple reports by NGOs, UN agencies and the WHO. (4).This appears to be a strategy for the de-development of health and social services impinging on all the population of Gaza.
The current systematic use of excessive force towards unarmed civilians, including children and journalists, is provoking a further crisis for the people of Gaza. Since 30 March 2018, snipers firing military grade ammunition have caused crippling wounds to unarmed demonstrators.(5) As of 23 April 2018,5511 Palestinians, including at least 454 children, have been injured by Israeli forces, including 1,739 from live ammunition according to the Palestinian Ministry of Health in Gaza. As of April 27, the death toll has reached 48 and additional hundreds wounded.
Even the BBC has shown films of the deliberate shooting of people who were standing harmlessly or running away, including childrenand journalists (6). The sniper-fire is mostly not to the head, with most of the wounds to the lower torso and legs. Dozens have needed emergency amputation of either one or both legs, and a further 1,300 required immediate external fixations which will entail an estimated 7,800 hours of subsequent complex reconstructive surgery if the limbs are to be saved. This is calculated maiming. More may die or incur life-long disability because of the degraded state of health service sand the prohibition by Israel of the transfer for the seriously wounded (7). How is Gaza to survive this situation? And meanwhile, the many that have lost non-emergency healthcare because of the ongoing lack of medicines and energy will be joined by many more now that all scarce resources are going to life and limb saving efforts.
Whilst various UN and WHO agencies have condemned Israeli actions, Western governments have not uttered a murmur and thus bolster the impunity Israel seems always to have enjoyed in its treatment of Palestinian society. Others who seek to document and to draw attention to events like this, including in medical journals, are often subject to vilifying ad hominem attacks, as have journal editors (8). These are matters of international shame.
Derek Summerfield, Institute of Psychiatry, Psychology & Neuroscience, King's College, University of London.
David Halpin, Retired orthopaedic and trauma surgeon. Member - British Orthopaedic Association.
Swee Ang, Consultant Trauma and Orthopaedic Surgeon ,Barts Health, London
Andrea Balduzzi, Researcher, University of Genoa, Italy
Franco Camandona, MD, OspedaliGaliera, Genoa, Italy
Gianni Tognoni, Mario Negri Institute, Milan, Italy,
Ireo Bono, MD, Onncologist, Savon, Italy
Marina Rui, PhD Università di Genoa, Italy
Vittorio Agnoletto, MD, University of Milan, Former MEP, Italy
(1) 50 days of death and ddestruction. Institute for Middle East Understanding. https://imeu.org/article/50-days-of-death-destruction-israels-operation-...
Emergency Delegation to the Gaza Strip. Physicians for Human Rights Israel.
-Unnecessary loss of life http://gisha.org/updates/8742
-Humanitarian Coordinator calls for protection of Palestinian demonstrators in Gaza alongside support for urgent humanitarian needs -https://www.ochaopt.org/content/humanitarian-coordinator-calls-protectio...
-Israel/OPT: Authorities must refrain from using excessive force in response to Palestine Land Day protests https://www.amnesty.org/en/latest/news/2018/03/israelopt-authorities-mus...
5) World Health Organisation Special Situation report- Gaza, Occupied Palestinian Territory. https://israelpalestinenews.org/who-special-situation-report-gaza-occupi...
The Palestinian Day of Return: from a short day of commemoration to a long day of mourning K. Elessi 27 April 2018, Lancet
Civilians, health workers, journalists and children killed and wounded march 30-april 27, 2018
-Horrific injuries reported among Gaza protesters https://www.map.org.uk/news/archive/post/828-horrific-injuries-reported-... Palestinians killed and hundreds injured in Gaza during demonstrations along the fence https://www.ochaopt.org/content/four-palestinians-killed-and-hundreds-in...
-New MAP film from Gaza: health workers under attack
-Adalah& Al Mezan petition Israeli Supreme Court: Order Israeli army to stop using snipers, live ammunition to disperse Gaza protests http://www.mezan.org/en/post/22754/Adalah+%26+Al+Mezan+petition+Israeli+...
Pressure on ‘The Lancet’ for Gaza letter another example of pro-Israel assault on freedom of expression 11 novembre 2014 |Catherine Baker pour Mondoweisshttp://www.aurdip.fr/pressure-on-the-lancet-for-gaza.html?lang=fr
Competing interests: No competing interests