The Gaza Strip's health-care system stands on the brink of collapse as bombings damage hospitals and ambulances and as generators run out of fuel, highlighting how quality medical care is a casualty of war.
Dire scenarios await Gaza's medical professionals.
They face dwindling basic resources such as power, water and anesthesia, compelling doctors to confront wrenching decisions on whose lives to save.
The growing humanitarian crisis is plunging health-care workers into the critical emergency planning that follows both human-made and natural disasters - assessing staffing and other resources, managing existing health needs on top of gruesome new ones, and looking out for their own welfare.
"When we are in a disaster setting or conflict, we usually have more patients than resources. We have to be very creative to be able to provide the best care for the most number of people," said Lindsey Ryan Martin, who is director of global disaster response and humanitarian action at Massachusetts General Hospital in Boston and has been monitoring the situation in Gaza.
The health-care crisis extends beyond Tuesday's deadly blast at al-Ahli Hospital in Gaza City. Aid organizations say the war continues to imperil an already beleaguered health-care system.
Gaza's Health Ministry said five hospitals were out of service as of Thursday and an additional 14 health facilities have closed because they lack fuel and electricity.
After Hamas militants launched an unprecedented cross-border attack into Israel on Oct. 7, Israel imposed a "full siege" on the Gaza Strip, cutting off electricity, food and fuel and limiting access to medical supplies and cross-border travel for high-risk diagnoses or operations.
Assessing and verifying the realities of medical care on the ground in Gaza has been difficult because of challenges communicating with medical professionals and limited access for reporters.
U.N. aid chief Martin Griffiths told The Washington Post on Wednesday that the hospital blast worsened the humanitarian crisis in Gaza, putting out of commission a hospital that treated 45,000 patients per year.
"Health workers, why would they stay?" Griffiths said. "And how can you move the sick people that we've already been discussing for the last few days, coming out of the hospital in Gaza City - how can you move them when they're in ICUs?"
After the blast at al-Ahli, Palestinian health officials said the flood of patients to nearby al-Shifa, the main hospital in Gaza City, exceeded the capabilities of medical teams and ambulances. They said doctors resorted to treating wounded patients on the hospital floor, some without anesthesia.
An anesthesia specialist at al-Shifa told The Post that bodies have been left in the hallway after attempts to save people failed. He shared a video that he had taken showing a chaotic scene: patients being treated on a teal floor, a man imploring others to take out a dead body to bring in another patient.
The hospital worker, who spoke on the condition of anonymity because he was not authorized to comment to reporters, worries about infections rising because of the lack of clean water and electricity to desalinate the water supply. He's already seeing infections, diarrhea and fevers on the rise and fears more dehydration in children.
The hospital worker said he last slept properly on Oct. 5, before the conflict began, and doesn't know whether his home is still standing. "It's also the last time I saw my wife and my kids," he said.
Erica L. Nelson, who has worked in humanitarian medicine for about 25 years, said Palestinian doctors at al-Shifa who are in her WhatsApp group are becoming more fearful of being targeted. "The additional component of 'We are at risk' has changed the tenor of the conversation," said Nelson, an emergency physician at Brigham and Women's Hospital in Boston.
International aid organizations in recent days added to the portrait of a tattered health-care system in Gaza.
The World Health Organization (WHO) said medicine for hundreds of thousands of patients is in short supply. Airstrikes have made operating ambulances and transferring patients to health facilities "extremely dangerous," according to Doctors Without Borders, which has staff on the ground in Gaza. The U.N. agency for Palestinian refugees, known as UNRWA, said Wednesday that fewer than half of its health centers could offer basic care to patients. All three organizations confirmed reports that lives are in jeopardy as generators run out of fuel.
The WHO has called on Israel to allow shipments of fuel as part of a deal brokered to permit humanitarian aid to Gaza.
"When fuel runs out, that may mean operating with flashlights or taking care of people with medications that don't require refrigeration and certainly not having lab services," said John Broach, director of the division of emergency medical services and disaster management at UMass Memorial in Worcester, Mass.
Broach said the struggle to care for patients injured in a war or disaster is exacerbated by the escalation of routine medical issues suddenly left untreated, such as people with well-managed diabetes now unable to take insulin spoiled when refrigerators lose power and chronically ill patients unable to fill prescriptions at shuttered pharmacies.
David Callaway, chief medical officer for veteran-led Team Rubicon, a Los Angeles-based nonprofit group that works closely with the WHO to provide relief in humanitarian crises, said there are dangerous consequences to health-care workers toiling nonstop with limited resources during disasters.
"Soon all the team is burned out, their empathy is gone and they are not making best decisions," said Callaway, who served as a battalion surgeon during the Iraq War and more recently oversaw humanitarian aid his organization provided in Ukraine.
The decisions health-care workers face in disasters are momentous: As they focus on the patient in front of them, they are acutely aware of massive needs elsewhere. "You feel like you have to put different values on different lives based on what you see in the moment," Callaway said. "Is a kid's life more valuable than an elderly person's?"
Thomas Kirsch, an emergency-medicine physician at George Washington University Hospital and an early practitioner of disaster medicine, recalled the moral dilemmas that came up when he was working with a Johns Hopkins team in Haiti after the 2010 earthquake.
Resources simply were not available to treat everyone in need, he said. "You can be forced into a situation where you can't do what's best for your patient, either causing a patient harm or allowing them to die," Kirsch said.
Those decisions, he said, are best taken out of the hands of the person providing care, by creating an ethics counselor or committee.
At the same time, disasters force providers to come up with systematic ways to tailor the care they are able to provide. "Can you scrub without soap? Re-use sterile drapes? Boil water on a stove?" Kirsch said.
Some superficial surgical procedures can be performed without anesthesia, Kirsch said, evoking images of Civil War-era operations. "But you can't operate on the heart, the lungs, the abdomen," he said.
Paul Spiegel, director of the Center for Humanitarian Health at the Johns Hopkins Bloomberg School of Public Health, says doctors in conflict zones operate in ways they were never trained to do. As a young general practitioner caring for severely mutilated patients during the Rwandan genocide, Spiegel said he followed instructions the best he could, amputating fingers and addressing other grisly wounds despite having no specialized training in those procedures. "You have no choice," he said. "You tell yourself you'll probably do it better than a layperson."
The health-care system in the Gaza Strip, which has been under Israeli blockade for 16 years, already struggled before the war. The Israeli Civil Administration controls the entry and exit of all patients and goods, which can restrict care. Recent attacks that damaged medical infrastructure are reminiscent of conflict in 2014, when 24 medical facilities were damaged and more than 15 health workers were killed in a 50-day Israeli offensive in Gaza.
Experts say war leaves lasting scars on health-care systems as officials face the daunting task of rebuilding facilities - and rebuilding trust in patients afraid to seek care after places of healing turned into danger zones.
"For months, years afterward, this community is still going to have a disrupted health-care system," said Rohini Haar, a medical adviser at Physicians for Human Rights who has researched the aftermath of war on health-care systems. "The folks in a community that are attacked are going to be experiencing this attack for years after."
The Washington Post