It has long been recognised that the health predicament in
which Palestinians have been placed is inexcusable. The
health-care systems in Gaza were already struggling with
demand, with a total of 3412 beds catering to a
population exceeding 2.1 million people.
The Israeli air strikes have displaced more than 80% of
the population, leaving them with limited access to
healthcare, food, water and other essential services. The
few remaining hospitals in Gaza can only offer limited
maternity, trauma and emergency care services and the
humanitarian need is catastrophic.
Since 2007, Israel has placed Gaza under siege, with the movement of people and goods being heavily restricted.
This has rendered the training of medical personnel by
international standards virtually impossible. Yet it is
recognised internationally that the health workforce is an
integral part of the health system, and no health service
can be delivered, no person cared for, and no health
outcome achieved without properly trained people.
Such highly skilled people take years to train and a
lifetime to educate.5There is no formal approved training
programme for reconstructive plastic surgery and burn
care in Palestine – either in the West Bank or Gaza.
Plastic surgeons play various roles in trauma centres,
such as in the management of facial injuries and hand injuries, performing limb-saving free tissue transfers managing burns and complex wound reconstruction with
flaps or skin grafts6 and are involved in 40% of military
trauma cases.7
Although this branch of surgery manages many
conditions other than trauma (especially cancer and
congenital deformity reconstruction), the persistent
conflicts around Gaza has led to a preponderance of war
related conditions which require skilled and specialised
plastic surgical attention. This has been recognised by the
Ministry of Health as well as the Palestinian Medical
Council. Access to training opportunities outside
Palestine, and Gaza particularly, have been severely
limited and constrained the ability for Gaza to build
capacity in this much needed area of surgical expertise.
In this context, a group was convened in 2018 by the
charitable organisation Medical Aid for Palestinians
(MAP) from UK plastic surgeons to support local Gazan
surgeons in a funded programme to build training
capacity for plastic surgery. The international faculty
consisted of the three Chairs of the British Foundation of
International Reconstructive Surgery and Training
(BFIRST), the Specialty Advisory Committee (SAC) in
Plastic Surgery for the Joint Committee of Surgical
Training in the UK, and Medical Aid for Palestinians,
and also a recent Vice President of the Royal College of
Surgeons of England (from 2020-23 the Chair of the
RCSEng Global Committee). The local faculty in Gaza
included the Director of Plastic Surgery for Al Shifa
Hospital and other experienced Palestinian doctors.
As part of the ongoing programme to educate and
improve specialty delivery in Gaza, three of the group
visited Al-Shifa Hospital in March 2023 to assist in the
delivery of best practice management and training in cleft
lip and palate patients. Further training visits had been
planned throughout the year on a monthly basis, to cover
the syllabus. 40 patients were reviewed as outpatients, all
with significant complex cleft and craniofacial
deformities. Local surgeons were taught advances in cleft
reconstruction, including much discussion around the
finer details of functional reconstruction and multi
disciplinary support. Following this preliminary visit, a
brighter future was anticipated, as the start of a consistent
educational program which would take root, grow and
flourish into a first-class reconstructive service to include
a training the trainers programme. Links were being
established to committed doctors in the UK to support
development work with case-based discussions and
telemedicine. It aimed to generate reconstructive surgical
self-sufficiency, to a clinical standard that would match
that expected in any developed society.
In lay terms, this might offer the chance to save a limb
instead of an amputation with subsequent permanent
disability. The best surgeons were selected from Al Shifa
Hospital, each candidate was interviewed and committed
to the program, and learning agreements were set.
Subsequently the group of Gazan aspiring plastic
surgeons met online on a bi-weekly basis to support their
learning needs, aiming to reach the equivalent standard of
the Inter Collegiate Fellowship of the Royal College of
Surgeons (FRCS-Plast) reconstructive surgeons. To date
the online tutorials included delegate-led sessions on
evidence-based medicine, governance, cleft surgery
hand surgery, lower limb trauma and burns management.
The delegates were uniformly committed and
hardworking. They made time to attend after-hours
teaching sessions, having worked full days in Al-Shifa
Hospital. They shared complex clinical cases for the
betterment of their patients. This process led to a close
affiliation of the faculty with the Gazan trainees and
senior surgeons, and the discourse on local vs.
international management of clinical cases by the trainees
was impressive and rewarding for both parties. Their
hunger to provide their patients with the best possible
care in the context of a besieged existence was
impressive. They were hopeful, respectful and resilient in
the face of unimaginable challenges.
Conversations about aspects of daily life (such as power
disruptions, supply shortages, and anxiety for their
families) gave considerable insight into the challenges
facing doctors on a daily basis. Recent developments
Since October 2023, four of the 18 doctors on the plastic
surgery training program have been abducted, shot at
close range, or killed by shelling. One such doctor was
Dr Ahmed Said Al-Maqadma born 19th June 1991. He
was a doctor who never hesitated to volunteer for long
and complex cases and never ceased in his love of
learning and sharing stories. He was a talented surgeon
with a bright future and had won a Royal College of
Surgeons of England Humanitarian Innovation
Fellowship which he was working on regularly with
frequent contact with a supervising surgeon as well as
RCS staff member. Until March 16th 2024, he was still
sending pictures of complex trauma cases, illustrating
where he had salvaged the limbs of children injured by
rocket fire and seeking further guidance on best practices
in caring for such devastating injuries, And then there
was nothing. He and his mother, a respected General
Practitioner, Dr Yussra Al-Maqadama, were shot at close
range by Israeli military force soldiers outside Al-Shifa
hospital on 24th March 2024. Ahmed and his mother
were an integral part of the future of health care in Palestine, and have been murdered. Ahmed leaves behind
him two children under five and his wife.
Recently it has also been reported that Dr Adnan al-
Bursh, the head of orthopedics at Al-Shifa Hospital died.
in an Israeli prison after four months of torture.
The BMA has put its position forward on Gaza but the
Royal College of Surgeons has not commented on the
Israeli attack on healthcare facilities and workers. Some
Muslim healthcare workers who have campaigned for
peace and speak up against war crimes committed by
Israel have been professionally persecuted.
Given the Social Determinants of Health, and Israeli
oppression in Gaza, it is inevitable that we must consider
the effects of the political context on health. In a leaked
ten-page document, dated October 13 2023 and featuring
the logo of the Israeli Intelligence Ministry headed by
Minister Gila Gamliel, a clear plan is described for
eradication of the Palestinian people from current
territory. The document states, “With the occupation of
Gaza, civilians in Gaza will move into Egyptian territory,
leave Gaza, and will not be allowed to return
permanently.13
It also proposes promoting a campaign which will
“motivate (Gaza residents) to agree to the plan” through
mass casualties. Gallant, the Defence Minister has
ordered a complete siege of Gaza to ensure no electricity,
no food and no fuel. If life in Gaza in impossible the
most “natural and obvious consequence” would be for
Palestinians to leave. The Israeli military force has
attacked over 600 healthcare facilities in the Gaza Strip
since October 7th 2023, including every single one of its
36hospitals, resulting in over 700 Palestinian medical
staff dead, 300 detained and over 1000 wounded.90
children a day have been killed by the Israeli military
forces in Gaza for over a year. This is equivalent to half
my local school’s population.
Every single day. In late-June 2024, Save the Children
reports that a further 21,000 children are estimated to be
missing due to the bombing and the ongoing war. This
would not be accepted anywhere else in the world. Over
44,000 people have been in killed by Israel since October
2023, and the Lancet recognises that this is a under
estimation with closer to 186,000 people killed by Israel
since the start of the war.
Many more people are still unaccounted for, buried
under the rubble15,16 and will continue to die with
malnutrition, lack of shelter in winter and complications from injuries without healthcare resources to care for
them.
The attacks on healthcare facilities greatly exacerbate the
desperate state of civilian lifetime in Gaza. The injured have
nowhere to be treated and can only look beyond its
borders, which are inaccessible to all but a tiny minority.
This tactic of war has been described as a deliberate
strategy of collective punishment, eradicating families
and infrastructure with the total annihilation of “power
targets” to be the “motivation” Gazans need to leave their
homeland forever.18 Health care facilities may be deemed
to lose their protection if they commit, outside their
humanitarian function, acts harmful to the enemy
However, the Israeli government has put forward no
credible evidence that would justify stripping hospitals of
their special protections.20, 21
The Israeli military force has made repeated accusations
that Hamas conducts military operations inside
hospitals.22 Many of these claims, however, have been
refuted under scrutiny from reputable journalists.
According to The Guardian: “…it’s clear the intended
and actual result of his campaign has been the systematic
destruction of the healthcare infrastructure for
Palestinians in Gaza”.25,26
A 2006 study in The New England Journal of Medicine
found that patients treated at a verified trauma centre had
a 25 per cent lower chance of dying than patients treated
at a non-trauma centre.27 This extends to the military and
warfare setting.28 Long-term complications are less likely
in the context of protocol determined trauma services
running out of Major Trauma Centres. Throughout the
57-year occupation of Palestine, there have been no
verified trauma centres developed in Gaza, with surgeons
frequently operating to manage mass episodes of trauma
in inadequate resources.29
Consequently, the people of Gaza continue to suffer and
die without adequate care, and will go on suffering long
after this war is over. The woeful residual health care
infrastructure and capacity from the surviving health care
personnel cannot possibly manage the immense demands
that post conflict care and rehabilitation will present to
the system.30 At present, local Palestinian doctors and
staff are left to do their best in the most primitive
conditions with exhausted medical equipment,
intermittent electricity and water supply and limited
medication for their patients amidst the constant sound of
shelling and drones overhead. When ambulance crews,
nurses, and doctors, who would be able to document and
verify the injuries sustained by the civilians, are killed, a diminishing number of witnesses are left able to testify to
atrocities committed. The adverse health impact on the
population as a whole is difficult in any circumstances;
with the decimation of skilled personnel, measuring long
term outcomes in the patient population will become
virtually impossible. The physical and psychological
sequelae of this war will be felt for generations to come,
and the substantial loss of health care infrastructure as
well as personnel will contribute greatly to the morbidity
incurred.31
Once the war is over, surviving Palestinians will be able
to slowly rebuild their homes, schools, businesses and
hospitals. But the human capital lost, so many doctors,
surgeons, paramedics, nurses and professors have been
killed and cannot be replaced for many years. The team
who had been training future reconstructive surgeons
mourn the loss of every person in Gaza and Israel and are
devastated at the loss of close medical friends and
colleagues.
Declaration of Interests
- Ms Swee Chai Ang is the Co-Founder and Patron of Medical Aid for Palestinians
- Victoria Rose is a member of the registered charity IDEALS – International Disaster & Emergency Aid with Long-Term Support
- Naveen Caveale is a member of the registered charity IDEALS – International Disaster & Emergency Aid with Long-Term Support
- Tim Goodacre is a Trustee of CLEFT, I IMET2000, and the Blonde McIndoe Research Foundation. Chair of Interface Uganda. Council member of the IDU.
Acknowledgements
There was no funding for this paper. No medical writer or editor was used for this paper. No patient information was included in the paper.
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