Since the start of the genocide over 10 months ago, Israel has targeted hospitals and health care staff in Gaza, deliberately damaging or destroying medical facilities throughout the Strip. Israeli Occupation Forces created what the UN Human Rights Office spokesperson described as “a pattern of attacks… striking essential lifesaving civilian infrastructure in Gaza, especially hospitals.”
In November 2023, Israeli Occupation Forces besieged the Indonesian Hospital in northern Gaza for days before targeting its main generator and raiding it. At that time, the hospital was the only facility treating patients in northern Gaza. Entire floors in the hospital were destroyed, and it was unclear if the hospital would be operational again. The facility, once again, began treating patients in the hospital’s ruins. Services however were severely impacted by Israel’s prolonged blockage of aid, crippling humanitarian responses. Dr. Marwan al-Sultan, medical director of the Indonesian Hospital, said the facility was already operating far beyond its designated capacity with extremely limited resources. He also said Israeli authorities denied the entry of medical supplies, even as medical delegations were allowed into northern Gaza beginning around May 2024.
Between June 15 and July 3, 2024, Dr. Jawad Shah joined a team of doctors on a medical mission with Rahma International to Gaza. At the time, there were four neurosurgeons known to the medical mission in Gaza, with two operating in the south and two operating in the north. Due to the large number of injuries and types of pathology in the north, Dr. Shah spent the majority of his time at the Indonesian Hospital. The Indonesian Hospital received most cases of neurotrauma in the north of the Strip, as it had access to limited micro-instruments and some imaging capacity.
In this interview, Sumaya Tabbah spoke with Dr. Jawad Shah about his experience in Gaza, the nature of trauma patients he treated, and the challenges of providing care. The interview has been transcribed and edited for clarity and brevity.
What did you see in Gaza?
I was anticipating a lot of traumatic injuries and illnesses in people who were already sick. I was also anticipating not having access to enough resources to treat patients. I wasn't sure whether the operating rooms would be equipped to do the type of surgeries I was trained to do. When I arrived in Gaza, I found that the number of cases and nature of the trauma were far larger and more severe than I expected. I was also shocked to see how young many of the patients were, children. Indiscriminate missiles, gunshot wounds, and bombs caused the injuries. Some patients suffered injuries by simply being in proximity to a building that was targeted. The very ill-equipped hospitals had very resilient staff who were impressive. They were very creative in the use of available equipment. Some equipment was recovered from the rubble of other nonfunctional centers in other locations and brought to reuse for other purposes.
Courtesy of Dr. Shah.Can you describe the nature of the trauma cases you treated?
There were three different categories or groups of patients that I saw. The first, of course, were those who were dead on arrival. There was nothing we could do. The second category was people whose injuries caused extreme damage to their organs and required significant surgical interventions, intensive care, and long-term postoperative therapy. These patients were likely to end up in a vegetative state, alive but absent. The third category was that of people who had injuries that potentially, with intervention, could reverse their fortunes and save their lives. The third category is where I felt I had to pay most of my attention; to people who could be saved if given proper attention and treatment.
I mostly saw patients who had an impact to their head. Skulls with multiple fractures, damage to the eyes, nose, and so on… some were missing these parts. But their brain could stay intact if the external damage was treated. Some cases were of patients who had brain injuries, internal bleeding, or swelling that was causing significant pressure. Removing that pressure could potentially help the patients. We didn't have all the equipment needed to treat them afterward. We often found ourselves forced to make decisions without conducting imaging or thorough examinations. There were spinal injuries that caused paralysis or partial paralysis. Intervention in those cases was sometimes needed quickly to relieve pressure on their nervous system.
Can you speak to the effect of the various types of weaponry used by Israel in Gaza?
I treated gunshot wounds, extracting bullets wedged in the bodies of the Palestinian patients. But, I saw more cases of shrapnel and pieces of metal inside these bodies than bullets. Oftentimes, we had to leave them in because taking them out would cause more damage.
I think the people who were directly hit by a missile died instantly. The cases that flooded the hospital were those on the periphery of bomb sites. There were many, many kids, small children, teenagers, and adolescents, the hospitals were filled with a fairly young crowd who sustained such injuries.
Courtesy of Dr. Shah.Can you describe a day at the Indonesian Hospital during your mission?
Emergency room physicians would first see the patients and then page us to help with specialized cases such as neurology, or traumatic or non-traumatic injuries. 95% of the cases, however, were trauma impact.
We often began planning surgeries as early as 3 a.m. By around 9 a.m., there were elective or semi-elective surgeries, which were essentially urgent, but they could be planned or structured. Those sorts of surgeries would probably go on until 5 p.m. In between surgeries, we would see patients in the clinic or the emergency room. There were also a large number of patients in the hallways, they would have their imaging and medical histories with them and would ask for help. It [was] difficult to move even down the hallways of the hospital without being stopped.
When the semi-elective or controlled surgical cases were complete, we would go back to [the] clinic again. People would be waiting in masses outside the door and then they would enter the clinic one at a time. Surgery would again be planned if needed. By 7 p.m., we would have time to eat something.
Food was mainly carbohydrates, but every second day hospital staff would bring meat which was a bit surprising to see because food was scarce and people in the area survived on rice and bread. They chose to honor us with their hospitality despite the circumstances. The local teams were incredible, high-quality health care workers who were clearly there intending to sacrifice their lives. They had an opportunity to move to other locations but they didn't. They are doing their best to protect their community and their loved ones with whatever abilities they have.
By sunset, we expected more patients with trauma injuries to see. The entire day would be filled with the sound of missiles, rockets, bombs, or something hitting the ground somewhere in the vicinity. Wounded residents were coming.
On average, I would see 50- 100 or so patients a day and complete 17 surgeries. As a neurosurgeon in the U.S., I would only be paged once or twice a day, or once every 10 days for emergency surgeries. Seeing 25-30 patients in a day in the U.S. would be considered busy.
Courtesy of Dr. Shah.Can you describe a case you treated that stood out to you?
There was one case where the patient had a fractured skull base, frontal and maxillary sinuses. There were underlying dural lacerations and brain contusions. You have pockets of air in the front of your skull and these pockets of air communicate with little holes in your maxillary sinus. When those fracture, sputum, and mucus [get] all over the brain. Tears often occur within the tissue covering of the brain called the dura. In case of such an injury, spinal fluid would leak and mix with that mucus, you can imagine how contaminated that is, which leads to an infection. It doesn’t stop there. If a fracture of this nature occurs, it could impact other neural/vascular elements in the head areas, causing tears, harming the ears, and the ability to hear and see, and damaging other critical structures.
To treat such an urgent case, specialized equipment is required. Equipment that wasn’t available, or was destroyed, in Gaza. For example, a high-speed drill was needed as opposed to a manual way of getting under the bone of the skull. Doctors used a jiggly saw, a primitive way of getting into the skull which could easily cause injury to vessels and eventually be fatal.
I did what I could to repair the damage, but there was no complete relief for the patient. They could have constant headaches, there could be underlying brain injuries and abnormalities that could only be detected by subtle testing and better imaging such as MRIs. The patient would be able to function, but time can only tell what sort of neurological repercussions they might face.
As a doctor, you have to make tough decisions about a patient’s quality of life. Is there an instance there that stands out to you?
I recall a patient that was around nine years old that had agonal breathing — the child was dying.
I was told that one of his pupils had been widely dilated, which indicated that there was a tremendous amount of pressure on that side of the brain, leading to what we call uncal herniation — a life-threatening emergency indicating that a part of the brain has moved location. In such a case, you would have to surgically open the area and take the blood out. Without a CT scan, you don't know what the actual pathology is. Sometimes you can be fooled, and the problem is on the opposite side, or it could be from lack of oxygen reaching the brain, meaning no surgery would help. In those circumstances, you're left with a very difficult choice of whether to do surgery knowing the patient has little chance of survival, there are limited resources, there are other patients, and at the same time, you're not sure what it is you're operating to repair because you don't have a CT scan available.
The 9-year-old boy’s vital signs were failing. Within the minute that it took me to walk over to examine him, his other pupil also became dilated and he lost his corneal reflexes. He had significant damage to his brainstem which was likely irreversible at that time. The boy died. As a physician, such a situation saddens me. Such cases are treatable given the proper resources and circumstances, we can do our best and follow up with the patient for months till they get better. This was not the case.
Courtesy of Dr. Shah.Is there anything else that stands out that you want to add?
Basic resources such as food and water are being restricted, there has been a wide degree of malnutrition, where even young men have osteopenia and weak bones.
In seeing that systematic brutalization of the civilian population, the thing that stood out was, that it doesn't appear that this is collateral damage. It appears to me that there's an intention to try and break the infrastructure and the population, whether or not they're direct combatants.
Basic infrastructure that has nothing to do with military operations is being deliberately damaged. This leads me to believe that this is a genocide and that the intention is to displace the population with no consideration for human rights and basic human dignity.
What was the trip to the north like?
We passed through the Karem Abu Salem crossing in the south to initially enter Gaza. But getting from there to the north was a precarious journey because of the Israeli military and atmosphere of lawlessness. We were transported by bus from the north to the south. The medical mission communicated consistently with the Israeli military and other international groups to inform them about our movement; where we're moving, how we're moving, and ensuring that we were not seen as a threat. We were stopped at a military checkpoint separating the north of Gaza from the south, where we were then questioned and we moved on. Civilians and other individuals were not allowed through the checkpoint.
The roads were destroyed, and rubble and rocks paved the way. There was a fear that we could not make it through to the north. A military operation could begin, and we could be stopped. Our journey was 30 kilometers, it took us up to 12 hours to get from the south to the Indonesian hospital.
Again, very, very difficult circumstances each way. It was a very exhausting journey in that sense, both mentally and physically.
