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War In Gaza: “We Are At The Limits Of What We Can Do”

With the advance of the Israeli forces, and due to the massive bombardments and ground fighting, Médecins Sans Frontières (MSF) teams are focusing their activities in the south of the Gaza Strip. In mid-December, we began supporting the Rafah Indonesian field hospital, specialising in post-operative care for victims of bombardments and explosions, while also working in other hospitals such as Nasser and the European hospital. Dr. Thomas Lauvin, MSF project coordinator, gives an update on the situation following his return from Gaza.

What is the state of the health system after more than 100 days of war and bombing in Gaza?

In the whole of the northern half of Gaza, the hospitals are barely functional or no longer functional at all. In the southern part of Gaza, as of 11 January 2024, there were still nine partially functional health facilities. This includes two major general hospitals, located in Khan Younis, a town that has been particularly hit hard by the bombardments and ground fighting: Nasser hospital in the centre and the Gaza European hospital, a little further out.

In collaboration with the Ministry of Health, MSF brought into service a hospital whose construction was almost complete: the Indonesian field hospital in Rafah, a town in the extreme south of the Gaza Strip. We decided to focus on post-operative trauma and burns care, to relieve the pressure on these two general hospitals, which are among the last to be operational, along with the much smaller Al-Najjar hospital in Rafah.

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This should enable Nasser hospital and the European hospital to receive new patients. It is estimated that around 10,000 people live on the site of the European hospital, while a further 10,000 live in the immediate vicinity and return there at night to sleep. Inside the hospital, these people, particularly families of patients or former patients, have built makeshift shelters, using scarves, blankets or scraps of fabric to hide themselves from view. To move around in the hospital, you have to sidestep between these makeshift shelters.

The situation at Nasser hospital is similar, and these hospitals are essentially short of space and beds to treat patients. They are completely saturated, which can make coordination between services difficult. This situation may change, however: following bombardments in the immediate vicinity of Nasser hospital, many patients and people sheltering in the area decided to flee. Nevertheless, waiting times are extremely long in emergency departments. Some patients are being sent back out on to the streets because the hospitals are unable to offer them treatment.

What is the situation in the town of Rafah?

Crossing Rafah is a striking experience: the city is full of displaced people, the streets are packed, people are building makeshift shelters directly on the footpaths, on roundabouts, in front of shops, while newly displaced people arrive from the north every day. There are throngs of people around bakeries, cash machines and water points - which are in desperately short supply - with crowd movements and, unfortunately, episodes of violence and people fighting. The sound of Israeli drones can be heard constantly. The tension is palpable, and, in the distance, you can see the ongoing bombing of Khan Younis and the columns of smoke billowing from it, while deadly bombardments frequently hit Rafah, particularly at night.

To what extent are hospitals spared from the fighting?

Hospitals are often considered by people to be safer places, despite a number of dramatic episodes around and in some of these hospitals. For example, MSF teams were forced to leave Al-Aqsa hospital, located in the Middle Area of Gaza, on 6 January, following an order from the Israeli armed forces to evacuate the adjacent neighbourhoods. Sniper fire, drone strikes and bombing made the situation untenable.

In the south, so far, we see some bombs falling right next to health facilities, with windows being blown out, for example. On 17 December, the maternity ward at Nasser Hospital was hit by gunfire, killing one patient and injuring others. Last week, there was extremely intense bombardment around the European hospital, with one bomb falling every minute for hours on end. They were falling all around the hospital. This makes access extremely difficult and dangerous for Gazans seeking treatment.

Last week, around the European hospital, there was extremely intense bombing, with bombs falling every minute for hours. They were falling all around the hospital. Working in such a tense environment is extremely difficult. Many of our staff were also forced to move. For the most part, they have been forced to flee zones of fighting or bombardment. The stress level of our teams is very high. When you spend a night hearing bombs, even if you're not directly affected, you don’t sleep. We work with teams who are often traumatised and, in any case, very affected by the whole situation.

From a security point of view, we are at the limits of what we can do. We have given the Israeli forces the coordinates of the health facilities where MSF works and the buildings where the teams are staying, but there is no guarantee that they will not be hit by a bomb or tank fire. On 8 January, an Israeli army shell tore through the building housing around 100 MSF team members and their families in Khan Younis. The shell failed to explode, which would have resulted in real carnage. The daughter of a colleague died as a result of her injuries. She was five years old. Three other colleagues were injured.

The town of Rafah is also gradually being squeezed as the Israeli army advances southwards towards the Egyptian border. As a result, the humanitarian space, or quite simply the area where it is possible to move around, is becoming smaller and denser.

What are MSF's activities at Rafah Indonesian field hospital?

We have opened a trauma and burns clinic. We do very few direct admissions and most patients are referred from a hospital. In the vast majority of cases, they have been victims of a bombing, the collapse of a building or the blast of an explosion. They have received first aid, undergone often life-saving operations and now need to be hospitalised for a relatively long time, due to the nature of their wounds and the risk of infection. Some patients have suffered serious fractures, sometimes open fractures, requiring external fixators.

Our main task is to prevent their wounds from becoming infected. Without such care, these patients could die. They could develop serious infections that could lead to gangrene, amputations or generalised septicaemia. In addition to their physical injuries, these patients have suffered significant moral trauma. They are staggered by the violence of their injuries and are often in a state of hyper-vigilance. They are worried and shocked and don't speak. We see this in our patients, but also in many people we meet in the street: they are stunned. Many of them have been forced to move several times, to take refuge in a place that has been attacked again. And when they arrive in the far south of Gaza, they find a completely congested city where the atmosphere is heavy with anxiety and fear.

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