Mark Perlmutter & Feroze Sidhwa
POLITICO / July 19, 2024
American surgeons who witnessed the civilian carnage of the Israel-Hamas war.
Gaza — In the United States we would never dream of operating on anyone without consent, let alone a malnourished and barely conscious 9-year-old girl in septic shock. Nevertheless, when we saw Juri, that’s exactly what we did.
We have no idea how Juri ended up in the Gaza European Hospital preoperative area. All we could see was that she had an external fixator — a scaffold of metal pins and rods — on her left leg and necrotic skin on her face and arms from the explosion that tore her little body to shreds. Just touching her blankets elicited shrieks of pain and terror. She was slowly dying, so we decided to take the risk of anesthetizing her without knowing exactly what we would find.
In the operating room, we examined Juri from head to toe. This beautiful, meek little girl was missing two inches of her left femur along with most of the muscle and skin on the back of her thigh. Both of her buttocks were flayed open, cutting so deeply through flesh that the lowest bones in her pelvis were exposed. As we swept our hands through this topography of cruelty, maggots fell in clumps onto the operating room table.
“Jesus Christ,” Feroze muttered as we washed the larvae into a bucket, “she’s just a fucking kid.”
The two of us are humanitarian surgeons. Together, in our combined 57 years of volunteering, we’ve worked on more than 40 surgical missions in developing countries on four continents. We’re used to working in disaster and war zones, of being on intimate terms with death and carnage and despair.
None of that prepared us for what we saw in Gaza this spring.
The constant begging for money, the malnourished population, the open sewage — all of that was familiar to us as veteran war zone doctors. But add in the incredible population density, the overwhelming numbers of badly maimed children and amputees, the constant hum of drones, the smell of explosives and gunpowder — not to mention the constant earth-shaking explosions — and it’s no wonder UNICEF has declared the Gaza Strip as “the world’s most dangerous place to be a child.”
We have always gone where we were most needed. In March, it was obvious that the place was the Gaza Strip.
The two of us had never met before this trip. But we both felt called to serve, so we packed our bags, leaving our lives behind in California and North Carolina.
We landed in Cairo around midnight and met up with the rest of our group of 12: an emergency nurse, a physical therapist, an anesthesiologist, another trauma surgeon, a general surgeon, a neurosurgeon, two cardiac surgeons and two pulmonary and critical care intensivists. All of us had volunteered to work with the World Health Organization through the Palestinian American Medical Association.
We were the only two surgeons in the group with experience in disaster zones. We were also the only two on the trip who didn’t speak Arabic, were not of Arab origin and were not Muslim. Mark is an orthopedic surgeon who grew up in a Jewish family in Penns Grove, New Jersey. Feroze is a trauma surgeon who grew up in a Parsi household in Flint, Michigan and worked with a Palestinian-Jewish cooperative in Haifa after graduation from college. Neither one of us is religious. Neither one of us has any political interest in the outcome of the Israeli-Palestinian conflict — other than wanting it to end.
At 3:30 a.m., we loaded into vans with the hundreds of bags of supplies our group had brought and joined a humanitarian convoy comprised of people from UNICEF, World Food Program, Save the Children, Doctors Without Borders, Oxfam and International Medical Corps, among others, heading to Rafah, the (now closed) crossing point between Egypt and Gaza.
The sight of thousands and thousands of semi-trucks parked alongside the highway for nearly 30 miles was truly something to behold — convoys of lifesaving aid turned into static walls of a tunnel directing us toward Gaza. Travel through the Sinai is slowed by the half dozen Egyptian military checkpoints in the peninsula; after 12 hours we finally arrived in the middle of the afternoon.
The Rafah Crossing functions like a rural American airport: one baggage scanner, odd procedures and minimal facilities. Scanning the medical and humanitarian supplies from the dozens of aid teams one bag at a time was inefficiency defined. But it was the only reliable way to bring anything into Gaza.
As Democratic Sen. Jeff Merkley of Oregon noted on the Senate floor, the process for clearing aid with the Israeli authorities is opaque and inconsistent. “Items that are allowed in one day can be rejected the next….” For this reason, everyone simply brought whatever they could as personal luggage — even surgical equipment — paying exorbitant airline baggage fees instead of bulk shipping rates. Now that Rafah is closed, even this route for resupplying Gaza’s hospitals has been cut off. (Israeli Prime Minister Benjamin Netanyahu, who has shown no signs of backing off, is scheduled to address the U.S. Congress on Monday. He will also meet with Vice President Kamala Harris.)
Finally, after 10 p.m., we were off to face Salah al-Din Road, Gaza’s famous “road of death.”
Salah al-Din Road is the main north-south highway of the Gaza Strip. To cross it requires relying on a remarkably ineffective process called “deconfliction.” The fact that “deconfliction” is so unreliable explains why “Gaza is the most dangerous place in the world to be an aid worker,” according to the International Rescue Committee. It works something like this: COGAT — the office of Israel’s Defense Ministry that coordinates between the Israeli armed forces and humanitarian organizations — agrees it will not attack traffic on a specific route for a specified period.
This coordination is done through — what else? — a smartphone app. When the road turns green on the app you have 15 minutes to get on and off the specified route, and you can only request deconfliction of a particular route every three hours. After a 40-minute wait, we got the go-ahead and our drivers floored it, dodging foot and donkey traffic all along the road.
Just before midnight, we finally arrived at our destination — Gaza European Hospital — where we were greeted by a sea of children, all shorter and thinner than they ought to have been. Even over their screams of joy at meeting new foreigners, we could hear Israeli drones humming overhead. We headed to our living quarters — half of our team slept in one room in the adjacent Palestine College of Nursing, while the other half slept in one of the hospital’s outlying patient-care areas — and spent our first night sleeping under continuous, room-shaking bombardment.
For our entire time there, we lived in constant fear that Israel would invade the hospital. Thankfully we never saw a single combatant, Israeli or Palestinian.
By the time we arrived, 59 percent of all the hospital beds in Gaza had been destroyed, while the remaining partially functioning hospitals operated at 359 percent of their actual bed capacity. The World Health Organization describes them as “partially operational.”
European Hospital is located at the southeastern edge of Khan Younis; it’s normally one of three hospitals providing elective general, orthopedic, neurosurgical and cardiac surgical services to a city of 419,000 people in southern Gaza. Now it functions as the only trauma center for well over 1.5 million people, an impossible task even under the best of circumstances. It is likely the safest and best-resourced city block in the entire Gaza Strip — and yet its horrors defy description.
We first noticed the overcrowding: 1,500 people were admitted to a 220-bed hospital. Rooms meant to hold four patients typically had 10 to 12, and patients were housed in every possible space: the radiology department, the common areas, everywhere. Next, we noticed the 15,000 people sheltering on the hospital grounds and inside the hospital — lining and even blocking the hallways, throughout the wards, in the bathrooms and closets, on the stairs, even in the sterile processing and food preparation facilities and the operating rooms themselves. The hospital itself was a displaced persons camp.
Then there were the odors: The intensive care units smelled like rot and death; the corridors stank like a kitchen filled with filth; the hospital grounds smelled of sewage and spent explosives. Only the operating rooms were relatively clean.
It’s what we imagine the first weeks of a zombie apocalypse would look — and smell — like.
While touring the hospital we walked through one of the ICUs and found multiple preteens admitted with gunshot wounds to the head. One might argue that a child could have been injured unintentionally in an explosion, or perhaps even forgotten when Israel invaded a children’s hospital and reportedly left infants to die in a pediatric intensive care unit.
Gunshot wounds to the head are an entirely different matter.
We started seeing a series of children, preteens mostly, who’d been shot in the head. They’d go on to slowly die, only to be replaced by new victims who’d also been shot in the head, and who would also go on to slowly die. Their families told us one of two stories: the children were playing inside when they were shot by Israeli forces, or they were playing in the street when they were shot by Israeli forces.
(The Israel Defense Forces did not respond to specific questions for this story, but in an emailed statement, it said, “The IDF is committed to mitigating civilian harm during operational activity. In that spirit, the IDF makes great efforts to estimate and consider potential civilian collateral damage in its strikes.”)
As we met Palestinian physicians and nurses working at the hospital, it was clear that they, like their patients, were physically and mentally unwell. Giving anyone a pat on the back dropped your hand between two unpadded shoulder blades and onto an exposed spine. In any given room one found staff members with jaundiced eyes, a sure sign of acute hepatitis A infection in such overcrowded conditions.
Many staff had no sense of urgency and often no empathy, even for children. We were initially taken aback by this, But we quickly learned that our Palestinian health care colleagues were among the most traumatized people in the Strip. Like all Palestinians in Gaza, they had lost family members and their homes. Indeed, almost all of them now lived in and around the hospital with their surviving family. Although they all continued working a full schedule, they had not been paid since October 7; health sector salaries are paid by the Ramallah-based Palestinian Authority and are always cut off during Israeli attacks.
Many of the staff were working at the Shifa and Indonesian Hospitals when they were destroyed. They were the lucky ones — they survived the attacks. Since October 7, at least 500 healthcare workers and 278 aid workers have been killed in Gaza. Among them was Dr. Hammam Alloh, a 36-year-old nephrologist at Shifa Hospital who refused to evacuate when Israel besieged the hospital in October.
On October 31, in an interview with Amy Goodman for Democracy Now!, the doctor talked about why he chose to stay: “If I go, who treats my patients? We are not animals. We have the right to receive proper health care. So we can’t just leave.” Eleven days later, Dr. Alloh was killed by an Israeli air strike on his home, along with three of his family members.
Among the medical staff who survived the assaults on the Shifa and Indonesian Hospitals, many were taken from those hospitals by the Israeli military. They all told us a slightly different version of the same horror story: In captivity, they were barely fed, continuously abused and ultimately dumped naked on the side of a road. Many said they were subjected to mock executions and other forms of mistreatment and torture.
After his home was destroyed and his family threatened, European Hospital’s director fled to Egypt, leaving an already overburdened hospital without its longtime leader. This sense of helplessness and disorientation was made worse still by the constant spread of hearsay about kidnappings, troop movements, food shipments, water availability and everything else of importance to survival and safety in a land under siege.
Cut off from the outside world and unable to access reliable information about the forces controlling whether they live or die, eat or starve, stay or run, rumors spread and amplified.
Several staff members told us they were simply waiting to die, and that they hoped Israel would get it over with sooner rather than later.
On April 2 we met Tamer. His Facebook posts show a proud young man and father who became a nurse to provide for his two small children — no small feat in a land with one of the highest unemployment rates in the world. When Israel raided Indonesian Hospital last November, he was assisting the orthopedics team in the operating room. He refused to leave his anesthetized patient. He said Israeli soldiers shot him in the leg, breaking his femur. His own orthopedic team cared for him, placing an external fixator to stabilize his shattered leg.
Next, Tamer told us, the Israelis came to his hospital room and took him, where exactly he doesn’t know. He told us he was strapped to a table for 45 days, given a juice box every day — sometimes every other day — and denied medical care for his broken femur. During that time, he told us, he was beaten so badly that his right eye was destroyed. As malnutrition set in, he developed osteomyelitis — infection of the bone itself — in his broken femur. Later, he said, he was unceremoniously dumped naked on the side of a road. With metal sticking out of his infected and broken leg and his right eye hanging out of his skull he crawled for two miles until someone found him and brought him to European Hospital.
(The IDF did not address specific questions about Tamer’s case, but instead emailed a press release responding to another outlet’s report of detainee abuse and torture at Sde Teiman. In it, the IDF denied mistreating detainees.)
When we met Tamer at the hospital for treatment, all that was left of him was the disfigured outline of a human being, his body crippled by violence, his eye surgically removed and his mind haunted by torture. A man who once healed others was reduced to constantly begging for pain medications, reliant on others for everything — and wondering if his wife and children were even alive.
Nearly all our patients arrived during mass casualty events. Khan Younis, a city in southern Gaza, had been under siege and bombardment since December. By the time we arrived on March 25 the town was inhabited by a combination of displaced persons from the north and locals who had not fled south to Rafah despite Israel’s threats against them. (Israeli forces frequently drop flyers or send texts demanding that Palestinians in Gaza leave their homes or shelters.) Extended families often concentrate themselves in as few buildings as possible. They told us they hoped that gathering in numbers would keep them safe — or at the very least, that dying together was preferable to dying separately.
We noticed that bombing seemed to peak at iftar when families were gathered together to break the fast during Ramadan with whatever food they had available.
Most of the bombardment was directed at empty buildings, but when an inhabited one was hit we’d see a flood of casualties. Those who made it to us alive met very specific criteria: They were trapped in part of the collapsed building that was accessible to people digging with their hands — and their injuries weren’t severe enough to kill them over the hours it took to free them.
Israa, a 26-year-old woman with a fair complexion and a quiet voice, arrived with our first mass casualty event around 4 a.m., on our second day in Gaza. In the chaos nobody could translate for us, so we were forced to improvise as she sobbed uncontrollably on a stretcher. All the ligaments in her right knee were torn; she had three open fractures in her two legs; and a massive chunk of her left thigh had been torn off. Both of her hands had second degree burns, and her face, arms and chest were stippled with shrapnel and debris. In the same incident a teenage girl came in with a lethal traumatic brain injury (she died the next morning) and a 7-year-old boy came in with a ruptured spleen (he recovered after several days).
We took Israa to the operating room. In the United States or Israel this would have been a 5-minute transition, but in the most functional hospital in Gaza it took more than one hour to get her there — working in such a severely compromised space, there was simply no way to get a trauma patient into surgery quickly. During her surgery, we realigned her broken femur, tibia and ankle in external fixators, explored an injured artery, cut chunks of dead tissue out of the massive wound in her thigh and her burned hands (a procedure known as debridement) and stopped her bleeding. It took three experienced surgeons almost four hours to do all of this. For the next 24 hours we were at her bedside almost continuously, knowing the traumatized and exhausted local staff couldn’t be expected to care for her properly.
After three days in the hospital, Israa, a mother of four, told us how she was injured: Her home was bombed without warning. She saw all her children die in front of her when the ceiling collapsed on top of them. Her relatives confirmed that her entire immediate family was buried under the rubble of their home. We didn’t have the heart to tell Israa that some of her children were probably still alive at that moment, dying unimaginably cruel deaths from dehydration and sepsis while trapped alone in a pitch-black tomb that alternates as an oven during the day and a freezer at night.
One shudders to think how many children have died this way in Gaza.
Two days later, while we waited in the preoperative area, one of the nurses pointed to a slight and clearly sick little girl. “Can you operate on her?” she asked.
“Who is she? We’ve never met her before.”
“Debridement,” the nurse said, shrugging and walking away.
That’s how we met Juri, the 9-year-old girl with the horrific injuries.
After washing away the maggots, we positioned her on her right side and got to work. We cut away four pounds of dead flesh, washing her wounds as aggressively as we could. Then we bandaged her up and booked her for another debridement the next day.
“Wain baba?” (where’s daddy?) she asked upon waking, her voice barely audible.
He’ll come soon, we assured her.
“You’re lying,” she told us, calmly. “He must be dead.”
As it turns out, Juri’s father wasn’t dead. We found him waiting for her in the pediatric ward of the hospital. He was a loving and gentle man who spent all day every day scouring a land in famine for anything his precious daughter would agree to eat. He told us how Juri was maimed: The family evacuated from Khan Younis to Rafah, as Israel demanded. He and his wife left their seven children with their grandparents while they desperately searched for food and water. They came back to the house bombed and destroyed, their children all severely injured or killed. Juri’s surviving siblings were at another hospital with their mother.
Over the next 10 days, in a series of operations, four surgeons put Juri back together as best we could by debriding her wounds, bringing the two ends of her femur together to close the gap in the muscles of her leg and giving her a colostomy so that feces no longer soiled her wounds. To have even a chance at a full recovery, Juri will need dozens more hours under the knife and days in a specialized pediatric ICU, which no longer exists in Gaza.
And for Juri, “full recovery” means a lifetime of severe and permanent disability.
Still, amid all this horror, there were moments of light. We took great joy seeing Juri’s personality resurface once her sepsis resolved. Instead of meekly calling for “baba” and screaming in pain when touched, she now acted like a sharp 9-year-old girl who knew she had her dad in her pocket. From then on, she refused to be sedated unless he promised her honey melon and phone calls with her siblings afterwards, famine and disrupted cellular services be damned!
On April 4 two young siblings, Rafif and Rafiq, arrived in the emergency room. An airstrike in Gaza City earlier in the war killed their mother along with 10 other members of their family and ripped through their immature and malnourished bodies. Both were being treated at Shifa Hospital in Gaza City when Israel raided the hospital for the second time in March. Medical Aid for Palestinians, a British charity, repeatedly requested that Israel allow MAP to evacuate these two critically ill children from Shifa. Israel repeatedly refused, according to MAP. Perhaps sensing what was to come, the children’s family members somehow got them out of the hospital, onto a donkey cart, and walked south for two days until they came to European Hospital. The siblings arrived with their IVs still in place.
Rafif, a keen and bright-eyed 13-year-old girl, had a chronic ulcer on her amputated right lower leg, an external fixator on what remained of her right leg and malnutrition that was obvious from her sunken face and recessed eyes. Still, she was without major complications. With access to food, proper wound care and future surgical treatment — none of which is guaranteed, but possible — she could survive. But her brother, 15-year-old Rafiq, was so severely malnourished that he could barely speak. The explosion that ripped his sister’s foot off and killed his mother had also sent shrapnel through his abdomen, tearing his intestines apart. He had open wounds on his buttocks that made it impossible for him to lie on his back or sit upright, and a broken left shoulder that had never healed, leaving it frozen. He screamed in pain with any attempt at examination and was constantly terrified.
We asked the hospital to admit Rafiq for tube feeding — pumping nutrients into his stomach until he grows strong enough to eat on his own — but the hospital lacked the equipment needed for this simple intervention, and the hospitals that had these basic capabilities have been destroyed. We told Rafiq’s family to look for foods that he would eat and to feed him slowly throughout the day, but we knew we were giving them false hope. If he is not evacuated from Gaza he will certainly die, for want of an $11 piece of plastic and a protein shake.
There were 3,412 acute care hospital beds in Gaza at the beginning of the war, 1.5 beds per 1,000 people, compared to 7.3 per 1,000 people in Ukraine. After the widespread destruction of hospitals in Gaza there are now approximately 1,400 acute care hospital beds for 2.2 million people, more than 88,000 of whom have been seriously injured by military weaponry in the past eight months.
With the medical resources left in Gaza, treating the 88,000 Rafifs and Rafiqs and Juris and Israas would take decades.
As Gregory Stanton, founder of Genocide Watch, a nonprofit whose mission is to eliminate mass murder worldwide, noted in his 2017 testimony on Myanmar: “Courts always come after a genocide is over, too late to prevent it.”
We had no illusions that two American physicians could prevent it, either.
We both believe — passionately —that Americans as a nation can stop what is happening. As a Jewish American, Mark has taken to telling everyone he can that support for what Israel is doing in Gaza has nothing to do with supporting Judaism or Israeli society.
The moment the United States cuts off military aid to Israel the bombs will stop falling and the troops will withdraw. We must decide, once and for all: are we for or against murdering children, doctors and emergency medical personnel? Are we for or against demolishing an entire society? Are we for or against starvation?
Are we for or against peace?
After two weeks, our time in Gaza ended.
But leaving Gaza is impossible to do gracefully.
As we handed Israa’s care off to a team of Canadian orthopedic surgeons, she begged her “American doctors” not to abandon her. We sedated her with ketamine to perform one last dressing change, and then snuck away before she fully regained consciousness, knowing we had no explanation for why she must suffer alone — while we were free to return to our lives and families.
We left on a Monday, just after sunrise. We were both consumed with guilt; we felt like we had no right to exit Gaza, that by leaving — and not staying permanently — we were deeply complicit in this mass murder.
To this day both of our consciences refuse to let us forget that we chose to leave.
At the Rafah border we encountered — once again — a gaggle of children. With no school to attend they gathered around us, some of them practicing their English. One of them was a 9-year-old boy, Ahmed. He grew up in this desperately poor and besieged territory his entire life, and had almost certainly never met anyone who had ever been outside of the Gaza Strip. He has no past and no present, and if nothing changes, he will have no future.
We both wondered: If nothing changes, where will Ahmed be on October 7, 2033?
On July 2 the Israel Defense Forces ordered Gaza European Hospital and the surrounding territory to be evacuated. European Hospital is now empty, and has been looted by desperate people trying to survive.
Mark Perlmutter is an orthopedic and hand surgeon who practices in Rocky Mount, North Carolina
Feroze Sidhwa is a trauma and critical care surgeon who practices in Northern California
