GAZA CITY, Gaza Strip – Doctors from the United States who rushed to the Gaza Strip to help the war wounded quickly learned that their challenge went beyond treating shrapnel injuries.
The eight American specialists found themselves operating on patients who had fallen victim to the 20-month-border closure that had crippled Gaza's health care system even before Israel's offensive against Hamas.
On Tuesday, the team removed a kidney tumor the size of a honey melon from a 4-year-old boy, Abdullah Shawwa, in a five-hour emergency surgery at Gaza City's Shifa Hospital.
The tumor was advanced and without quick intervention Abdullah would likely have died, said Dr. Ismail Mehr, an anesthesiologist from Hornell, N.Y. Doctors in Gaza didn't have the expertise to operate on him and Abdullah's father had been unable to get him transferred quickly to Israel or Egypt.
Even after the surgery, Abdullah's prognosis is uncertain. He'll need followup treatment, including advanced chemotherapy or radiation, which are not available in Gaza. But it's been difficult for Gaza patients to get out, ever since Israel and Egypt closed the borders in response to the violent Hamas takeover of the territory in June 2007.
The closure also dealt a further blow to Gaza's underdeveloped health care system, which lacks sophisticated equipment and key specialists. Hospitals often operate on generators because of disrupted power supplies, and spare parts for some machines are unavailable.
On the eve of the war, Gaza's hospitals had run out of 250 of the basic 1,000 health care items, and were short on 105 of 480 essential drugs, including some cancer medications and anesthetics, said Mahmoud Daher, a representative of the World Health Organization.
In this vulnerable condition, disaster struck. On Dec. 27, the first day of the war, Israeli warplanes bombed Hamas security compounds across Gaza, killing about 220 people, most of them Hamas police, and wounding some 300 people, according to Health Ministry officials.
Shifa, Gaza's central hospital, was overwhelmed.
Its six operating theaters couldn't cope with the waves of seriously wounded. Staff nurse Jihad Ashkar, a 22-year veteran at Shifa, said he had never before seen so many people with multiple injuries that required hours-long surgeries.
"The injured people waited for many hours to enter the theater, so we lost many injured people because we haven't the equipment or operating rooms," said Ashkar.
More than 1,280 Gazans were killed in the three-week offensive, according to the Palestinian Center for Human Rights. More than 4,000 people were hurt, including about 500 critically. The 600 most difficult cases were allowed passage to Egypt.
But the war has also changed the lives of those with lighter injuries. Policeman Sabri Elawa, 25, said he was the only one in his 60-member unit to survive the initial bombing raid. Hit by shrapnel in the right leg, he limps and moves with a walker.
On Monday, he stood in an unruly line at Shifa for several hours, waiting to pick up a proof-of-injury document. With paper in hand, he went to two charities in a failed search for the office that would pay the 500 euros promised to each wounded person by the Hamas government.
Two of his relatives, Maisa and Sami Elawa, accompanied him, seeking emergency payment for their 3-year-old son, Zaher, who suffered a broken hip and burns on the face and chest in a shelling attack near their home.
The couple has no income, except for handouts from relatives. They said they can't afford the medication for Zaher, who was lying on a sofa in the modest living room Monday, alternating between crying and smiling. "He cried for a whole week," Maisa, 22, said of her son.
She said she's not sure the relief money will ever materialize. "All of them have forgotten us. We are the victims and every government just looks for their" jobs, she said.
With many of the wounded either sent home or to hospitals abroad, Shifa has largely settled into its prewar routine.
Some of the exhausted Palestinian doctors have been given relief by foreign medical teams that have arrived in Gaza since a cease-fire took hold Jan. 18. Doctors Without Borders set up a white tent clinic on an empty lot in downtown Gaza City and Jordanian specialists are to stay for several months, operating a 44-bed field hospital.
The eight Americans, including a plastic surgeon and a radiologist, performed more than 15 procedures since arriving Sunday, including skin grafts and cancer surgery. The group, which also carried cartons of medical equipment, is to stay through Friday.
Dr. Saeed Akther, a Pakistan-based urologist originally from Lubbock, Texas, performed the surgery on Abdullah, the 4-year-old with the kidney tumor. Palestinian doctors crowded around to watch, one even bringing a portable step so he could peek over the heads of the others.
"The (local) surgeons could not have done it here," said Mehr. "I am not knocking their ability. You could tell when we were doing it, they had lots of questions. They just would not have been able to handle a tumor this size."
Abdullah's father, Mussalam, a butcher in Gaza City's outdoor market, said the boy was diagnosed only a month ago, after his belly kept swelling. He said his request for treatment outside Gaza was still hung up in bureaucracy when the foreign doctors arrived.
For followup treatment, Abdullah would have to go to Israel. Even during the 20-month closure, Israel has permitted several hundred patients a month — some 900 at its peak — to reach Israeli hospitals for treatment not available in Gaza.
Each trip across the heavily fortified Erez crossing into Israel requires a complicated series of permits from officials in Gaza, the West Bank and finally Israel's Shin Bet security service.
In recent months, the number of rejections on security grounds has increased, said Miri Weingarten, of the Physicians for Human Rights in Israel, which helps Gaza patients.
She said about 1,000 referrals a month are needed, but that in the period before the war, only about half that number were reaching Israel.
Israeli Foreign Ministry spokesman Aviv Shiron said Gaza's Hamas rulers are responsible for any hardship in Gaza but that Israel has gone out of its way to ensure ongoing medical care.
"Israel has answered every request made by the Red Cross, the U.N. and other humanitarian organizations, regarding health care in Gaza," he said, adding that "any claims that Israeli policy is harming the health care system in Gaza are false, completely untrue."
However, international aid groups say the pre-war trickle of aid shipments is not sufficient to deal with Gaza's growing humanitarian crisis. Rebuilding homes, factories and several health care centers is estimated to cost about $2 billion. Many of the wounded will need rehabiliation.
The American doctors were careful to stay away from politics — the lifting of the closure is linked to complex negotiations between Israel, Hamas, Egypt and others.
But Dr. Ahmed Colwell, an emergency room physician from Sioux City, Iowa, said at least the sick should be given relief.
"It's inhumane ... to not allow them to even have basic medical care," he said.
