Gaza: “Complete devastation of the health care system”

My name is Amber Alayyan. I’m a pediatrician and I’m the medical program manager for Palestine, Afghanistan, and Haiti with Doctors Without Borders [MSF].  What I'd like to talk about after having heard what my colleagues have seen and what we've all seen [in Gaza], including teams with MSF, is how exactly the health system is collapsing and where we go from here.

MSF has been working in the Gaza Strip for about 15 years. We've been doing orthopedic surgery, trauma surgery, burn surgery, or mental health, or a combination of all three. Since the start of the war, we started working in Al-Shifa [Hospital]. We've been working in Nasser [Hospital]. We have a hospital in Rafah that does postoperative, inpatient, and outpatient care. We have a team working on post-delivery care for pregnant women, screenings for malnutrition, primary care, and working with chronic diseases. What we have seen is the complete devastation of the health care system, and when Thaer [Dr. Thaer Ahmed, who also spoke] talks about not being able to get midazolam or diapers or inhalers in, it's absolutely true.  

Horrific choices facing doctors struggling to provide care

When the medicines do get in, how do they get to the right place and how do they serve the people in need? There is a huge focus, for example, on surgical care, which is absolutely necessary, but when you have a child who's having a seizure and needs to be treated, there's not enough medicine for the person who needs to be sedated to be intubated or the child who's having a seizure, and doctors are being forced to make choices in those cases. 

Hospitals rely on quota systems for how many drugs they keep in their pharmacies and their stocks in each department. They have to choose between fully stocking an operating theater, ICU, or the emergency room, and this is where you have doctors faced with horrific decisions [about] having to intubate and amputate children and adults without anesthetics in emergency rooms. 

Part of the reason for this is the lack of accessible medications at that time, [and that] we have internally displaced people living in hospitals, sheltering in hospitals because they have nowhere safe to go. What that means is they’re staying in hospital beds. So, what does that mean for injured people? They arrive, they get a quick and dirty surgery in an emergency room or in an operating theater, and they have nowhere to be hospitalized afterward or when they are, they're lost in the hospital and our teams spend all day searching for the patient that they just operated on 12 hours before. What does this mean over the long run? The longer this war goes on, the longer these wounds have to rot, and I mean really rot—the infections are getting worse and worse, and it's horrific. It's horrific for our providers, and it's absolutely horrific for these patients.

The hospitals can't cope with the burden. No hospital in the world—high income, low income—could cope with the amount of injuries that we're seeing and the needs that we're seeing on the ground. [This] is a very resilient population—a hospital may be rendered dysfunctional one day and a week later, you have the entire staff showing up saying, okay, “Let's clean it up. Let’s start over again.” 

When we talk about helping this population, we talk about [how] we need access. Our doctors need access. Our nurses need access. They need to not be targeted. We've had ambulances targeted. We've had convoys of medical personnel targeted. We've had hospitals targeted, clinics targeted, the shelters where staff [stay ] have been targeted.

Immediate need for access to the north 

In order to be able to ascertain whether there is malnutrition, for example, across the Gaza Strip, you need to be able to do surveys among the population, which means you need to be able to access and touch the population. What we have been able to do is extrapolate [the numbers of malnutrition cases] from the few patients, the relatively few patients, that we've seen in our clinics. What we know is that we can’t access a whole host of children and pregnant and lactating women [in the north], who are the most vulnerable, and we know that they don't have access to food, or what food they have is exorbitantly expensive. To be able to access this population we need safe access for the medical providers. 

As I said, two populations are particularly vulnerable, pregnant and lactating [people]. Women who were already facing iron deficiency anemia before the war, which puts them at risk for hemorrhage during birth. With the war, it puts them in a state of undernourishment or potentially malnutrition, which means that they can't breastfeed their children properly. The milk doesn't necessarily come in, and it's definitely not enough. The other [vulnerable] population is children under two years [old], which is the breastfeeding age. 

There's not enough space for us to work closely with the mothers to help them start lactating again. We can't even access them. And to be able to do that, you have to have day-to-day activities with those women, and that is not something that's possible for us right now. 

Women are squeezing dates into handkerchiefs, into tissues, and feeding their children with some sort of sugary substance to nourish them. The consequences of this over the long run mean that there is a lack of bond between the mother and the child. It means that there are physical and psychological delays for these children [as they] develop, and in the future—for those children who do grow up—it means that they're more at risk of having high blood pressure, of having diabetes and other complications.

The sooner we act, the better

How many people are going to need prosthetics? What is the socioeconomic status of Gaza going to look like in five years, in three years, in three months? How can this population that is so incredibly resilient rebuild itself? 

The longer the war goes on, the harder this becomes. It's not impossible, but it just becomes harder and harder and harder, and the sooner we act the better ....We have teams that are trying to provide mental health services [and] it's very difficult because many of those teams are themselves victims of trauma, and that makes this an ongoing battle for us. Our doctors, our nurses, our health care workers, the cleaners—anyone who works in the health care system—they are completely exhausted. And on top of that, they have to worry about the safety and security of their own families. They're dealing with the losses of their own homes, and they have all of this going on in their minds while they're trying to carry out very heroic acts with their patients. 

So there are some that have definitely displayed signs of acute stress... Part of it is that they want to keep working because that serves somehow as the therapeutic methodology for them, [and] there are others who simply can't work, and we have to be obviously very patient with that and accepting of that because it's absolutely understandable. They're completely, completely traumatized. We have many patients that come for primary care consultations, just to be able to talk, just to be able to get some kind of TLC, some sort of care and compassion. The mental health needs are astronomical. 
 
I've been going for five years to Gaza. I have very good friends, very good colleagues there, and I can't offer them words when they tell me [about] the tragedies, when they tell me the stories. What they want are actions ... It's not enough for us to just say, “I'm so sorry this has happened to you.” There are just no words.