Conflict and Health: Providing Care in Conflict Zones
On October 7th, 2023, approximately 1200 Israelis were killed and hundreds more were abducted by Hamas, a Palestinian terrorist group.1 As of November 2024, the ensuing Israel-Hamas war in the Occupied Palestinian territories has killed more than 43,000 Palestinians, according to estimates reported by the United Nations (UN).2
In addition to the growing number of casualties, many more Palestinians have been injured or have gone missing. The destruction of Palestine’s health care infrastructure, which was already severely compromised by previous conflicts,3 has left many individuals without treatment for newly onset injuries and chronic conditions that predate the current regional war.4,5
According to a September 2024 UN press release, nearly 900 health care personnel have been killed in the Occupied Palestine territories since October 7th, 2023.6 Nonetheless, some physicians from the United States and other parts of the globe have felt compelled to travel to Gaza on high-risk medical missions to provide care and support.
Among these courageous doctors is David Hasan, MD, MSc, professor of neurosurgery, biomedical engineering, and neurology at Duke University School of Medicine in Durham, North Carolina. His first mission to Gaza was toward the end of December 2023, followed by a second mission in the spring of 2024.
In a recent interview, Dr Hasan shared with us what it was like to provide medical care in an active war zone and how the experience completely changed his perspective.
What led to your decision to travel to Gaza amidst such conflict?
Dr Hasan: Before October 7th, I was busy with my clinical and academic appointments, and I was very focused on myself in terms of my research and clinical experience.
Then October 7th happened, and it was a trigger point for me. I’m emotionally connected to that part of the world because parents are originally from the West Bank.
Seeing the war play out on social media also provoked strong emotions within me, as well as a desire to help.
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My advice to people is to never underestimate what you can do and how can you help. With determination, an open mind, and a good attitude, you can move mountains.
I was able to enter Gaza, as well as walk through a kibbutz and the grounds of the Supernova music festival, so I got to see the pain and suffering that was happening on both sides.
In summary, that’s how I got involved — social media exposure, familial connection to the region, and the desire to make a difference and help.
There’s limited literature and guidance regarding triage protocols in areas plagued by conflict. What was you and your colleagues’ approach to this?
Dr Hasan: There was constant bombardment and shelling around the hospital. At one point, I fell off a stool I was standing on while operating [due to the impact]. Another time, an air conditioning unit fell onto the bed on which I was sleeping due to violent shaking. You just go in without knowing what to expect and adapt as you go.
That’s compounded by 50,000 people living in the hospital with no electricity, water, medical supplies, or anesthetics at times, as well as a limited number of operating rooms, only 1 computed tomography (CT) scanner, and scores of people who are severely injured. Everyone is in survival mode. In the hospital we were in, there were only 5 beds, but you might have 20 or 30 people coming in for treatment at a time. You have to decide who’s going to have the best chances of survival.
Conducting surgeries in the hallways and operating on 2 patients in the same room was not uncommon. We did amputations and C-section deliveries without anesthetics, while patients were awake.
Even though I’m a neurosurgeon, sometimes I had to go in and help my colleagues with amputations and open trauma, and I learned as I went.
We had 12- and 13-year-old kids learning how to do X-rays. Kids in their mid-teens were learning how to do CT scans.
When you’re operating in survival mode, it’s amazing to see how people are able to step up, learn, and adapt. The collective mentality was improvisation.
What resources in the Occupied Palestinian territories are most depleted, and how did you deal with these deficits?
Dr Hasan: There was a shortage of everything. Because the infrastructure has been destroyed, there’s no sanitation connection, water, or electricity. There’s no one collecting the mountains of trash piling up, and there are no medications or antibiotics. As I mentioned, at times we did surgeries without anesthetics or adequate pain medications.7
The main issue is nutrition. Some people had enough food to get by, but many didn’t have access. Because it is an active war zone, mobility is limited and it is difficult for humanitarian aid to reach those who need it most.
It’s not just the depletion of supplies, but issues of sanitation and famine. There’s a lack of everything.7,8
What types of medical conditions did you encounter and treat most often while in Gaza?
Dr Hasan: We were focused mainly on trauma, particularly head injuries. Due to this narrow focus, there were about 350,000 people with chronic diseases who were not able to be treated.9 For example, people with cancer had no access to treatment. Patients would show up to the hospital with a brain tumor, but no trauma, and we were unable to help them.
The biggest issue was infectious disease. People are basically living on top of each other and there’s no access to anything.10 We have hundreds of thousands of kids with hepatitis A, diarrhea, malnutrition, and recently, polio.
Can you share more about your background and what experience(s) prepared you for working in this setting?
Dr Hasan: I had zero experience with humanitarian aid or this level of trauma. The trauma that many of physicians are exposed to during medical training is nothing compared with what you see in a war zone. The only things I could control were my attitude and ability to improvise. Short of that, I had no previous experiences to prepare me for this situation.
As a physician, how do your priorities change when managing populations with such vastly limited resources?
Dr Hasan: When I went on the first trip to Gaza, we would operate on everyone. On the second trip, we started asking ourselves, ‘will this person survive to be functional?’ Because not only do you have to worry about the patient’s survival, you also have to think about there being zero access to rehab and antibiotics.
It feels like an actual battleground in that you don’t operate on the most severely injured, but the ones who can functionally survive. The [way that it’s] different from an actual battleground is the proportion of kids who need treatment. Children comprise approximately one-half of the population in Gaza. Statistically, any detonation will affect children many children. As a physician, you want to save everybody, especially children. In an active war zone, however, you quickly learn that you can’t do that.
On a personal level, how do you begin to recover from experiencing and witnessing this level of trauma and stress? What has helped you return to some semblance of normalcy or psychologically recover?
Dr Hasan: There is no way to undo these scenes in your head. When I returned from each mission, it was comforting to quickly jump back into my practice. It also induced guilt, however. The first time I came home, I refused to eat good food for a week because of this sense of guilt. I thought, ‘how dare I eat while all of these people still can’t get food.’ That guilt was the hardest thing to deal with.
The way I coped was by helping from outside. I worked with different groups and was able to funnel 25,000 pounds of food, daily, ambulance services, millions of dollars in medications, dialysis units, neonatal incubators, and more into Gaza. We also bought 4000 dignity backpacks for women who weren’t able to shower for months. These backpacks included items like shampoo, toothbrushes, shoes, underwear, and sanitary pads. One bag was able to make a difference in people’s lives.
These efforts helped with the guilt, but you’re never truly the same after an experience like this. You just try to compartmentalize and continue to do your best.
How have your experiences in Gaza had a lasting impact on you as a clinician?
Dr Hasan: My priorities in life have definitely changed completely. This kind of experience really humbles you and makes you grateful. Prior to this experience, I was more focused on my publications and grants. I still do these things, but I don’t find as much joy in it after being a part of these aid efforts. If I can make a difference in a single person’s life in Gaza, to me, that is worth so much more than grant money and publications.
I built a one-of-a-kind coalition of physicians and nongovernmental organizations (NGOs) that include Americans, Palestinians, Israelis, and Europeans to work together on different efforts. I wanted to bring a polarized people back together. The war will end at some point, and afterward comes recovery. The only way to facilitate meaningful recovery is to build back a sense of trust, collaboration, and coexistence.
It’s amazing what you discover about yourself as you go through a new journey. Before October 7th, 2023, I never envisioned myself talking to heads of governments and making a global difference. My advice to people is to never underestimate what you can do and how you can help. With determination, an open mind, and a good attitude, you can move mountains.
What recommendations do you have for your fellow clinicians in the US and abroad about what can they do to provide care or otherwise support efforts in areas of conflict?
Dr Hasan: I think as physicians, we all have a moral compass and North Star. One of the most important things is to lead by example and be completely blind to race, color, religion, and other differences. When you come to help people, you have to stay neutral and focus on providing health care. It is your job is to care for people and not participate in polarization, as hard as it may be. Yes, you are a human being and can’t help how you feel, but your job takes priority.
Simple things like the dignity backpacks can make a huge difference, psychologically and emotionally. Physicians can also work with pharmaceutical companies to collect medications, equipment, and devices.
While physicians can also volunteer in aid efforts, there are plenty of other ways physicians can help without entering a war zone. If you have an online connection with a physician or medical student from the affected areas, be supportive, listen.
If you are influential in your hospital, you can also transport kids from affected areas to your hospital to receive free treatment. We’ve done this in the US through Heal Palestine.
Buying winter clothing is another way to help from afar.
There are so many ways to help. You can’t limit your mind to, ‘I’m a physician and I’m just going to go and operate.’ You have to think more broadly.
This article originally appeared on Neurology Advisor
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