Letter from Gaza: inside the Nasser hospital

A couple of years ago my wife told me that I was getting pompous and boring and too entangled in the politics of senior medicine. So I signed up with the British army to go to Afghanistan, treating injuries in the field, and have since worked in other hotspots, including Haiti. Last December, the charity Médecins du Monde (MdM) asked me to go to Gaza to help local surgeons. It wasn’t a frontline mission, rather a ten-day stint working through the backlog of wounded from battles with the Israelis—the last big one being the December 2008 invasion, which the Gazans say left 1,000 people dead and 5,000 wounded.

When I arrived in Jerusalem my Palestinian driver, Ibrahim, took me up the Mount of Olives. He showed me how to tell the houses apart. Those in the Israeli part of Jerusalem have a small white tank on the roof. They need nothing more as they have no shortage of water. But the houses of Palestinians have roofs crenellated with big black water tanks. The water supply is under Israeli control and, apparently, is cut off most of the time.

Then he pointed out the Garden of Gethsemane, the Church of the Holy Sepulchre, and the Al-Aqsa Mosque shimmering across the valley below us. He told me the Israelis are excavating under the mosque looking for remains of their original temple. But he thinks that they are undermining the foundations of the golden-domed mosque, the site where Muhammad is said to have ascended to heaven. “If the mosque collapses,” he said quietly, “there will be a world war.”

The next day we set off through verdant farmland to the only entrance into the Gaza Strip, that narrow band of Palestinian territory tucked between the sea and the Egyptian border. This is Hamas country, run by the democratically elected but violent opponents of Israel.

The new border post is huge and looks like an airport terminal. Before the 2008 war, 170,000 Palestinians crossed every day to work in Israel. Then, one day, the gate was shut and has never opened again. Only aid workers are now allowed to cross.

After entering Gaza—where I got a new driver and car, a white four-wheel drive with an MdM flag flying boldly on the roof—we set off down the coast to the Nasser hospital, 15 miles south of Gaza City in a place called Khan Yunis.

At the hospital I was met by a quiet, elderly consultant wearing a tie (having decided not to wear one, I felt a little underdressed). Dr Mohammed eyed me carefully. His English was good but he spoke so softly it was hard to hear. The hospital’s waiting room was packed. There was a lot of shouting and pushing and mobile phones trilled out Arabic songs. We weaved through the throng to the consulting room. Once inside, the door had to be closed against the crowd to prevent everyone outside from joining us.

We saw about 50 cases. Gunshot wounds through the thigh, the back, the arm. Infected wounds. Young men with hopeful eyes and damaged bodies, shy smiles and dark beards. They were Hamas: the terrorists who stood against the might of Israel and were slaughtered. They are portrayed in the western media as crazy fundamentalists, but they were just kids with fluffy beards hoping their lives hadn’t been ruined before they had barely begun. Dr Mohammed seemed pleased that we agreed on almost all the cases. By the end of the day my head was whirling with pictures of faces and shattered limbs.

The following two days were spent in the operating theatre, working through the cases. Dr Mohammed has good hands. I assisted and made noises of appreciation, wondering how I would feel if a foreign doctor came into my operating theatre and did little more than murmur. Between cases, I was pulled out into the noisy corridor to do television interviews. All the while, a scrum of patients waited at the door of the operating theatre suite, hoping to speak to Dr Mohammed. He was never hurried, never angry.

MdM had told me that the surgeons at the Nasser hospital wanted to be taught some of the latest orthopaedic techniques. I had my reservations, not only because I’m not sure how useful these techniques are, but because ten days isn’t long enough to teach such complex work. I also wasn’t confident the hospital had the resources to back up such high-tech medicine.

It’s not that there is any lack of motivation to practise medicine. A few years ago, I was told, the Israelis stopped Gazan medical students continuing their studies in Jerusalem, so the Islamic University of Gaza started a medical faculty. Its centrepiece was a six-storey laboratory block, but when I visited it was a pile of rubble. It had been destroyed by an Israeli air attack in December 2008.

Despite this, the students were as keen as mustard. When I met the dean, an ex-surgeon, he told me that if they had selected their students purely by grades then the whole intake would be female. But obviously this would have been impossible, because “how would we have any surgeons?” I tried not to reveal my feelings about this ridiculous rationalisation of reverse discrimination.

Back at the hospital, I quickly realised there was little I could teach Dr Mohammed, even if he wanted to learn. The registrar certainly didn’t. He was a fly boy, with shifty eyes and a faint sneer. He pretended not to understand English and fumed at my attempts at Arabic.

The fourth day brought a difficult operation. The patient’s thigh had been broken in the middle by a bullet. It had become infected and the break hadn’t knitted properly. A previous surgeon had cleaned out the infection but, six months later, the bone still hadn’t healed. Inside, we found that much of it was dead and the operation slowed as we realised the complexity of the problem we were facing.

If someone breaks a thigh, there are several ways you can treat it. The old-fashioned way is to string the patient up in traction. This is safe, but recovery takes three months. Since then, the Swiss have designed metal plates, and the Germans have invented clever nails that allow you to fix the fracture and get the patient up on his feet the next day. But if you get the plate in the wrong place, or the nail is badly inserted, you can do terrible damage to the bone. And if bacteria get in, infection will spread and the repair will fail.

In Britain, we do these operations in super-clean rooms. The Nasser hospital’s operating theatre was supposed to be sterile but there was blood everywhere, the anaesthetist was away for long periods, and there were too many people bending over the wound and brushing our sterile gowns. My worst fears were realised when, after five hours spent fixing the plate to the patient’s broken femur, a fly landed on the bone. I could have wept. The wound was now contaminated. But the surgeons around me just brushed the insect away and carried on, unaware of my horrified expression under my face mask.

My eyes followed the blood-frenzied fly across the operating theatre to the annex where the stainless steel sinks stood for surgeons to wash their hands. There, the anaesthetist had taken his shoes off and was washing his feet under the taps, lifting one leg into the sink, then the other. This is part of the cleansing ritual that precedes daily prayers, but for a surgeon the scrub sinks are sacred in a different sense—part of the ritual of cleansing before surgery. There was a collision of cultures here. If I said I did not think using the sink in this way was appropriate would I find myself accused of insulting their religion? Did it matter that someone had washed their feet in the sink meant for sterilising hands? I’m not sure. Perhaps I was the one being unreasonable. I bit my tongue.

The lack of a sterile environment was far from the only difficulty facing Gaza’s doctors. One day, the lights in the operating theatre went out five times during surgery; the back-up generators weren’t working because of fuel shortages. During the rounds of the ward, I saw dressings taken off patients with no sterile precautions, the wounds left dripping in the bed. I had washed my hands but others had not. Eventually I physically guided one of the nurses to the sink. He glowered at me and grudgingly washed his hands.

It is always tricky working in a foreign country, but Gaza was more difficult than usual. Some of the older people seem resigned or have taken refuge in religion, but many of the youngsters radiate anger. They drive like lunatics, as if they are going to die tomorrow. They shout at each other even when they are not arguing, but when they do argue, it is with guttural rage. They are not just angry with the Israelis, but with the rest of the world for not caring. They are even angry with those who are trying to help, perhaps because they feel we are patronising them. Maybe we are. One thing is certain: you cannot get it right. I felt very uncomfortable.

On day eight we couldn’t operate because of some administrative problem. Dr Mohammed was furious and for the first time I saw him lose his temper. But in typical Palestinian fashion, the rage and frustration suddenly subsided. He decided to make a “virtue of necessity” and declared we would have a picnic instead. It was beautiful weather and he had an open invitation from a local farmer (whose son he had treated) to picnic on his land.

We drove south from Khan Yunis towards Rafa, a town that is bisected by the Gaza-Egyptian border. This is a dangerous area. The crossing is closed for all but one day a month, so it presents a dismal, derelict sight. The customs building is riddled with bullet holes. Shortly before we reached the border we turned off down a dirt track that runs just inside the Gaza boundary fence. We entered a gentle world of horse-drawn carts, farmhouses set in groves of grapefruit trees, and beautifully manicured and irrigated fields of peas, tomatoes and fruit trees. The farmer was happy to see us and eager to show us his farm. The peas were as sweet as any I have tasted, the clementines melted in the mouth, the grapefruits were heavenly.

Yet the rural idyll was marred by sporadic shooting in the distance and, high above us, an Israeli balloon with reconnaissance cameras continuously surveyed the area. Between us and the Egyptian border fence 200m away there were massive earthworks, as if a herd of giant moles had gone to work. These are the mouths of the famous tunnels that lead into Egypt. They are the lifeblood of Gaza— through them comes cement, flour, fuel and the other goods it needs, which the blockade of its land and sea borders prevents it importing.

Throughout my stay, sleep was difficult. The windows rattled in the wind and any loud noise made me imagine a group of militants was picking the locks to take me hostage. Just as I would finally drop into a troubled slumber, the faithful were called to prayer at 5am.

On my last day I met with the medical director of the hospital, a young paediatrician who was given the post because he is a Hamas party member. He asked me what I thought. I started to tell him, but then stopped at once. His eyes had glazed. He didn’t want to hear. Our conversation was only a formality. We shared offers of undying gratitude and, clutching my gift of a Hamas scarf, I left.