The health system in Gaza is in a state of collapse
A medical supplies store was bombarded today
Referrals to medical care outside the Gaza strip are suspended

Since the start of the Israeli military strikes against the Gaza Strip, true to Sunday, 16:00, 282 dead (including 20 children and 9 women) and about 700 wounded persons (including 130 children and 28 women) have been identified by Gaza hospitals, including more than 100 seriously wounded. According to local estimates, dozens are defined missing, presumed to be trapped beneath destroyed buildings. The Palestinian ministry of health in Gaza claims that the number of dead is even higher. The Gaza health system is in a state of collapse and cannot provide an adequate response to the growing needs. The closure imposed by Israel on all Gaza crossings, including the total closure of Erez Crossing since last Friday, prevents the evacuation of patients and wounded persons and deepens the human tragedy occurring in the Gaza Strip.

Governmental hospitals full to overflowing

Hospitals in Gaza cannot deal with the heavy load of injured people continuing to arrive since Saturday, and today as well. In the two main hospitals in the Gaza Strip there is a shortage of beds, despite the fact that all wards were evacuated in order to admit wounded people. As a result, wounded people are filling the corridors of the hospitals. The endless flow of new wounded and the need for beds has led to a suspension of care for dozens of other patients, including cancer patients, cardiac patients and other chronically ill patients. These were sent to their homes for the duration of the crisis.

Shifaa’ hospital

According to Dr. Hassan Khalaf, director general of the hospital, true to Sunday at 13:30, 240 wounded people had been admitted to the hospital and the numbers of wounded were continuing to rise hourly. The majority of injuries were a result of direct hits, of shrapnel and of shock waves, caused by bombardments from the Israeli air force and buildings collapsing on top of their inhabitants.

The hospital has operated in emergency mode since Saturday, and its 12 operating rooms have been working 24 hours a day, with all medical teams on site. The heavy overload of wounded and the shortage of operating rooms led to the use of four of the wards in the obstetrics departments as general surgical rooms, and the hospital has stopped admitting women for deliveries. The outpatient clinics in the hospital, and four Intensive Care Units in the burns department of the hospitals are now being used for hospitalization of the wounded from the Israeli attacks.

The European hospital in Khan Younis

According to Dr. Zaki Zakzouk, a senior oncologist in the hospital, 30 seriously wounded people are hospitalized there. Most of them are suffering from head and neck wounds and are in urgent need of complex neurosurgical procedures. All these need a pulmonary intensive care unit, but due to the severe shortage of beds in the department, only half are connected to ventilating machines, and others are ventilated manually. There is also a shortage of type O minus blood. A shortage of refrigeration rooms and of ambulances is preventing transfer of blood from Shifaa’ hospital.

Nationalisation of private medical centers

As part of the attempt to deal with the emergency, private clinics including ‘Almamdawi’, the Red Cross clinic and others, have stopped their regular activities and are now functioning as hospitalization units for the wounded, to which governmental hospitals are now referring patients.

Damage to medical equipment stores

Today, 28.12.08, the largest medicines and medical supplies store of the ministry of health in Gaza was bombarded. It mainly serves Shifaa hospital. The store, located next to the Falastin football stadium was completely destroyed and a large amount of medical supplies was destroyed.

Referrals out of Gaza suspended

Erez Crossing has been hermetically closed since the morning of Friday 26.12.2008, and the soldiers have been evacuated from the crossing. Physicians for Human Rights-Israel has been informed that the authorities at the crossing would not longer be handling applications for transfer of patients and wounded persons to medical care outside Gaza, including urgent and lifesaving cases. This information was confirmed by representatives of the Palestinian Subcommittee for medical referrals, who told us that their attempts to coordinate passage or even communicate with Erez Crossing authorities had failed.

Of the hundreds of wounded, PHR-Israel has the full details of 25, all of whom are suffering from serious injuries and must be urgently referred to external advanced medical centers: 14 of these are unconscious in the ICU at Shifaa hospital and are inimmediate danger of their lives. Seven others suffer severe orthopedic injuries and are in danger of losing limbs. Four others suffer from internal injuries. All tried to apply to Erez crossing for permission to exit Gaza and all failed so far.

Jordan has declared its willingness to admit wounded people, but in order to access Jordan, patients must receive an exit permit from the Israeli authorities to exit via Erez Crossing.

Rafah crossing

Despite the declaration of the Egyptian government according to which it would open Rafah crossing to the wounded, no wounded people have been evacuated via this crossing, for several reasons:

  • Political disconnection between the Hamas government in Gaza and the Egyptian Government due to the Israeli attacks prevent proper coordination between Egypt and Hamas. Egypt claims that Hamas is preventing the passage of patients to Egypt through Rafah.
  • The severity of the cases: dozens of wounded people are not transferred to Egypt due to the severity of their condition. The majority of these are head injuries and internal injuries. Most are unconscious and are in need of artificial ventilation and a medical team to accompany them on ambulances to advanced medical centers in Cairo, a six hour journey from the Rafah Crossing, Doctors in Gaza fear that many of the wounded may not survive the journey.
  • Shortage of ambulances: As already reported by PHR-Israel in detail on 22.12.08, only half of Gaza’s 58 ambulances are functional. The remaining ambulances are working full time since Saturday and cannot be spared.

The Israeli military is issuing threats to civilians

Many patients have phoned PHR-Israel over the past 24 hours, reporting that during the night they had received recorded threats over the telephone. The first recorded message ordered them to leave their homes due planned bombardments. The second message warned that anyone aiding militants or hiding arms would be exposed to bombardments.

Appeals for humanitarian assistance

Today Israel enabled the opening of Kerem Shalom crossing for entry of some humanitarian goods. However, according to the Palestinian ministry of health in Gaza, these supplies are not sufficient. Due to the severe shortage of medical supplies and medicines (105 sorts of medicine, 225 types of medical items and 93 types of laboratory supplies are missing), as detailed by PHR-Israel on 22.12.08, PHR-Israel and PMRS today received an urgent appeal from the Gaza Ministry of Health for transfer of medical supplies. Among the supplies asked for are basic sterilization equipment, clothing for medical teams, needles, dressings, anaesthetics, catheters, medical gases, oxygen, monitors and medicines. The overall value of necessary supplies requested from PHR-Israel is half a million US dollars. PHR-Israel is working to find funding sources and to coordinate transfer of the supplies. PMRS has initiated an emergency call to support First aid, ambulances services, Individual relief and rehabitation of injured people the call is for 1 million$

Summary

The current attack found the health system in Gaza in a state of near-collapse due to the blockade imposed upon it for the past year and a half, as well as previous closures. Even before this crisis the system was working in a severely restricted manner. Now it must handle wounded people who are in need of complex care by expert professionals, which in the current situation it cannot provide.

Targeting of civilians and/of medical facilities is a breach of international humanitarian law. The targets chosen by the Israeli military include also clearly civilian installations.

As occupying power currently in effective control of the area, Israel, which is currently carrying out a massive military operation in the Gaza Strip, must bear responsibility for the wounded of the attack, enable their access to hospitals able to care for them, respect medical neutrality of related facilities and allow entry of all necessary medical supplies for hospitals to be able to handle the wounded people.

For further details contact:

Ran Yaron, PHR-Israel, 0547 577696 ranyaron@phr.org.il

Bahia Amra, Palestinian Medical Relief Society, 0599407847 bahiaamra@hotmail.com

Mahmoud Abu Rahma, Al Mezan Gaza, 0599609310, mahmoud@mezan.org

Physicians for Human Rights-Israel Gaza Update 5.1.09

Attacks on Medical Personnel and Serious Obstacles to Evacuation of Wounded within the Gaza Strip

After calling yesterday for international intervention for an immediate ceasefire, PHR-Israel today sent two urgent requests to the Israeli Military Chief of staff regarding protection of medical teams, internal evacuation of the wounded, and evacuation of the wounded to external medical care. We have also called upon foreign diplomats to press Israel to enable “corridors” for referral of the wounded to external medical centers, until the implementation of a ceasefire.

Moreover, PHR-Israel has collected personal testimonies from patients it had assisted in the past, in order to hear from them about conditions on the ground during the current Israeli offensive.

Below is the information collected by PHR-Israel on medical issues since the start of the land offensive:

Attacks on medical personnel:
· December 31, 2008: Helicopter fires on medical crew evacuating wounded: in Jabal Kashif in northeast Gaza a crew set out to offer assistance. While approaching the bleeding victim on foot, they were hit by helicopter fire. Dr. Ihab Madhun, medic Muhammad Abu Hasireh, as well as the injured victim, were killed.
· January 3, 2009: Second attack on a house after medical crews enter to evacuate the wounded: The house of the Dabbabish family in Sheikh Radwan had already been bombarded. As a crew of medics dressed in medical vests arrived on the scene to tend to the wounded the house was bombarded for a second time. One person was critically wounded: Ayyad Ahmad.
· January 4, 2009: Ambulance belonging to the Al Awda Hospital in Beit Lahiya was hit by helicopter fire. Arfa Abd al Daim, a senior volunteer medic was killed and two other medical personnel were critically injured.
· January 4, 2009: Tank fires on ambulance during attempts to evacuate a family in Tel Alhawa. Inass Fadil Naim, Yassir Shabir and Rifaat Abdel Al were killed.

Difficulties in internal evacuation of the wounded:

· According to the head of the Palestinian emergency health services in Gaza Dr. Mu’awiya Hasaneen, and the MoH spokesperson Hammam Nasman, there are many wounded and dead, but access to them is impeded by ongoing gunfire.
· According to information collected by PHR-Israel, the ICRC, the Palestine Red Crescent Society (PRCS) and the hospitals meet severe difficulties in evacuation of the wounded, due to the ongoing fighting, due to the refusal of the Israeli army to enable passage between the north and the south of the Gaza Strip, and due to unwieldy bureaucratic procedures, whereby the security forces demand coordination between the Palestinian Civil Affairs Committee and the Israeli authorities at Erez Crossing for each case. It should be noted that during hostilities the ICRC – of which PRCS is now a member – should enjoy full authority and protection for evacuation of wounded.
· The PRCS reported to PHR-Israel that they have no way of dispatching ambulances without prior coordination since ambulances that set out for evacuation duties at AlAtatra were fired at by apache helicopters. They appealed to PHR-Israel after attempts to coordinate passage via the ICRC have failed since yesterday. AlAwda hospital in Beit Lahiya also asked for our assistance since they must send out ambulances to AlAtatra and Tel Zaatar but cannot dispatch ambulances without being shot at. The hospital is urgently requesting coordination to enable evacuation.
· According to our information, between 2 hours and 8-10 hours pass between a request by the ICRC for coordination until the Israeli authorities actually coordinate passage. In some cases teams waited for 24 hours for coordination
· A shortage of ambulances has been reported: patients are often evacuated in private vehicles either because of shortage or because ambulances cannot access the areas.

Cases:
· January 4: Hasin al ‘Aiedy, along with his two brothers and their families, among them 6 injured awaiting evacuation, called PHR-Israel after being trapped in an isolated area south east of Gaza City surrounded by the Israeli Army. Hasin al A’aiedy and two of his brothers live together with their families in an isolated area, empty of other residents, halfway between Nezarim junction and Karni Crossing. Soon after the Israeli Army began their ground operation in the Gaza Strip, the house sustained missile fire. As a result of the bombardment, sections of the roof were destroyed, many of the doors were unhinged, all glass was broken and the water pipes burst. Six members of the family sustained injuries: Kamala, 80 years old, was hit in the face and head; Taha 80 years old was hit in the face; Da’a, 18 years old was hit near her eye, Nur, 16 years old was hit on an entire side of his body and is bleeding; Raad, 13 years old was also sustained injuries to half his body and is bleeding; and Lid, 3 years old has sustained shrapnel wounds to half his body. To the damages inflicted on their home, the family members, 28 in all (15 children and 8 adults) are now outside in an open area without food, water, light or heat. Since the bombardment, Israeli troops have surrounded the area on all sides. The family members cannot move more than several meters from where they are currently located because every movement – even to look for water- is met by artillery fire. Upon receiving notification of the event on the morning of January 4th, PHR-Israel immediately contacted the Israeli District Coordination Office at Erez Crossing and was assured the army would look into the matter. Since then, the DCO has not got back to PHR-Israel regarding the incident; the status of the al ‘Aiedy family remains unchanged. Members of the family and representatives of PHR-Israel have contacted the International Committee of the Red Cross (ICRC) in Gaza with hopes that they may be able to evacuate the family members with one of their ambulances, however as noted, the Israel army has surrounded the area and until now has not allowed for the evacuation of the wounded and trapped victims. For additional information see Haaretz Article:

·January 4th: PHR-Israel tried to coordinate the evacuation of a family of 6 via the coastal road: The family had left from ShifaaHospital towards their home in Southern Gaza. Salah a- Din St. was blocked near the area of Nezarim Junction so the family took a detour via the coastal road. There they were fired upon by tanks. The family called ShifaaHospital to send an ambulance. At that time others informed PHR-Israel that they were unable to coordinate the evacuation. PHR-Israel immediately called the Israeli District Coordination Office (DCO) at Erez, who after much pressure claimed that they had sent an army vehicle to the scene though were unable to locate the family’s car. The DCO claimed that without a telephone they were unable to locate the family. They also informed us that they had not received any requests to coordinate the evacuation, after which they told us that the Palestinian Civil Affairs Committee had in fact inquired regarding the transfer. The lack of clarification and the misunderstanding have made clear to us that that there is now total chaos regarding the coordination of the ambulances to evacuate the wounded. The fate of the family is unknown.

Hospitals: Needs vs. Reality and the need for evacuation to external medical care
 According to Physicians for Human Rights-Israel medical experts, in a situation of multiple casualties with multiple injuries in any medical system, medical preparedness will be conducted according to the following three principles:
1.Every wounded person with multiple injuries in need of pulmonary support (ventilation), medicinal support or surgical procedures needs an Intensive Care Unit (ICU) bed.
2.Due to the simultaneous arrival of high numbers of wounded persons, there is a need for an increased number of surgical teams: one surgeon and two nurses per patient. Each patient will also need an operating room and necessary equipment: monitor, ventilation machine for every ventilated patient, automatic syringes, haemodynamic medications and blood products.
3.Since even in advanced medical systems there are usually not enough teams and equipment, there is usually need of emergency modification of the health system to increase services, import of external surgical teams and equipment, and arrangements with external hospitals for referral of the overflow of wounded. Such hospitals must be as close as possible.

According to information collected by PHR-Israel, although over 2,400 people have been injured since the start of the operation, and 110 people were injured between the 3rd and the 4th of January, there are currently less than 100 ICU beds and only 32 operating rooms throughout Gaza.

There are 190 surgeons in Shifaa’ hospital, working around the clock, but the system lacks expert capacity on neuro-, vascular-, orthopedic- and open heart surgery.Moreover, the security situation, as well as damage to roads and bridges, is preventing staff from reaching health facilities. Foreign teams currently in Gaza include 2 surgeons from A Norwegian NGO, NORWAC, (1 thoracic surgeon and 1 anesthesiologist working at ShifaHospital) and 5 Egyptian surgeons.

An ICRC team of war surgeons has been waiting since Friday to be granted access to the Gaza to address the lack of surgical staff. They have now received notification that they will be granted access when Erez re-opens but the crossing is closed.

Referrals:
At the start of the land operation, all crossings were closed, including Israeli controlled Erez Crossing and Egyptian controlled Rafah Crossing. The army claims Erez was opened for a few hours this morning, but it re-closed at noon. As a result any overflow of patients at any given time cannot be referred outward, resulting in overload and inadequate medical care inside Gaza.
Internal access to the crossings is also impeded: While 45 ambulances are waiting on the Egyptian side to transport patients to Egyptian hospitals, the security situation and damage to bridges and roads prevent ambulances from reaching Rafah
It should be noted that the Israeli Ministry of Health has expressed its willingness to admit wounded from the fighting. Israeli hospitals have prepared for their absorption. However, the closure of Erez Crossing by the Ministry of Defense prohibits such arrangements at present.

Supplies
 Medical supplies: A substantial volume of supplies was delivered to Gaza last week. Trucks with drugs and consumables reached all MoH hospitals yesterday but shortages are still reported.
Food supplies: WFP, which provides food aid to some 350,000 Gaza residents, estimates that the daily need for all Gaza population would be 1,200 mt of basic food commodities, meaning 40 trucks a day. WFP currently needs to deliver about 4,000 mt of food commodities (150 trucks) asap to fill its warehouse.
Despite the entry of some food and medical supplies last week, and contrary to Israeli claims – the amounts are not sufficient for the needs of the population and the needs are growing. The current closure of the crossing poses a real threat to the population in general and the hospitals in particular in this respect.

Personal Testimonies: Life under Fire

Testimony from Khan Younis, 5.1.09 11am
” Conditions in our neighborhood are very dangerous. Buildings keep collapsing because of the bombardments and shelling of houses on top of their inhabitants. The Israeli army is shelling anything that moves, especially to our east. There is electricity only 6 hours a day, and then it’s off for 16 hours. When there is electricity we call our family inside Israel, they hold their telephone to the television so we can hear what is happening, because we have no radio or TV. Around us is much destruction and a terrible noise of bombings anddust and smoke. In order to cook, we light a wood fire on the steps, because on the roof it is too dangerous. There is no food left at home, we eat whatever we can find with a lot of zaatar. The kids can’t sleep. They are very much afraid and the noise of the planes is terrible. Lest night we slept perhaps two hours. Half an hour ago an F-16 bombed the Jam’iyat AlNour building. It’s a medical association with equipment and everything. It’s very close to us. We keep hearing the shells and the gunfire. At night some people were called and told to leave within 24 hours. In this area there are no armed people, no guns, no tunnels. Often they never destroy anything in the end, but yesterday one family reached us by luck half an hour before their home was bombed.
(the son of a 67 year old patient we have assisted in the past. He asked not to use his name).

Testimony from AlTufah neighborhood, 5.1.09, 11:30am
 The situation is very bad. The worst is we have no water. There is really so little, and what there is is not clean. People use what there is, usually not for drinking. There are whole areas cut off from water. There is no bread. People stand in lines of hundreds of people outside the bakeries and there is no bread. Three days with no electricity and the cold is killing. There is no gas either. We managed to smuggle in some fuel through the tunnels but it smells so bad in the food we’re sure it’s unhealthy. There is no food supply. We eat what’s left over, mainly rice and potatoes. In the Jabel AlRis area, where Jaber’s family lives [he is referring to a 15 year old boy who lost both legs in a shelling by the Israeli army in March; because he is disabled and his aunt also lost a leg at the same time, their escape from danger is even more difficult – PHR-I], the danger is very present and many have escaped as far as they can. We have internally displaced people. Here at AlTufah, too, many houses were destroyed by shelling and bombardments. People escape but the planes and helicopters chase them. They are in the air all the time, nonstop. Yesterday five people escaped to the beach and were shot there, from the air. It’s a lie that most of them are armed. In every place civilians are killed due to collapse of buildings and on the beach. There is no escape. No safe place. In Gaza everything is so close. I am less than a kilometer from the border and I cannot avoid seeing or hearing. Eyewitnesses told me that the Israelis are also using cluster munitions, and I myself have experienced explosions with strange smoke and very strange sounds.
Sameh, 23, blogger www.gazatoday.blogspot.com – was in touch with us regarding the case of Jaber.

Testimony from Deir AlBalah, 5.1.09, 11:45am
 The situation is very bad, there is deep fear, and desperation. People around here aren’t leaving their homes. There is no water. We drink from containers and these are running out. Before, we had 6 hours of electricity [per day], but now it’s been a whole day and there is no electricity. So it’s cold, there is no way to heat water, food or our home, and we cant refrigerate our medicines. The border to Egypt is cold, and it’s all full of checkpoints and tanks. To get to hospital [this is a person with a chronic disease – PHR-I] I have to find someone with a car and they take a lot of money for each journey because of the danger. My brother’s kids are very fearful, the sounds of explosions are very loud, day and night, and it’s not even in our area. But there is no water or food and we are all trapped in our homes.
Shadi, 24.