Dr. Seema Jilani is currently a senior technical adviser at the International Rescue Committee, where she leads their emergency health responses globally. In December, she went to Al-Aqsa Hospital in central Gaza to aid the humanitarian effort there. More than twenty-six thousand Palestinians have been killed by Israel’s military campaign in Gaza, which began after Hamas’s terrorist attack on October 7th. Since that time, Gaza’s health-care system has been on the brink of collapse, and Israel has refused to allow sufficient food and medicine into the territory. I recently spoke by phone with Jilani, who has practiced medicine across the world, including in numerous conflict zones, about her experiences in Gaza. Our conversation, edited for length and clarity, is below.
Where have you worked before you ended up in Gaza?
I have been in and out of Gaza and the West Bank for the past nineteen years. I was previously in Gaza in 2005, prior to Israeli disengagement, and then again in 2015, right after the 2014 war. And also again several times in and out of the West Bank. I have worked in Afghanistan, Iraq, Lebanon, Egypt, Turkey, Pakistan. And I have worked on refugee rescue boats off the coast of Libya.
When you’re working in Iraq, or Pakistan, or Afghanistan, who are you working with, and in what capacity are you working there?
A variety of N.G.O.s, some that are tiny and made up predominantly of volunteers. I was working with the International Committee of the Red Cross in Lebanon when I lived there. I usually am working in a pediatric capacity as a clinician. In Turkey, I was teaching refugee and migrant medical students how to advocate for their patients.
So when did your most recent stint in Gaza begin, and how did you get into the territory?
We departed from Cairo on Christmas Day. The International Rescue Committee, in partnership with Medical Aid for Palestinians (MAP), deployed an emergency medical team to provide emergency and lifesaving medical care. That was facilitated in part by the U.N. Office for the Coordination of Humanitarian Affairs. We were a team of surgeons, a high-risk obstetrician, an emergency-care doctor, an anesthetist, and myself, as well as other I.R.C. folks.
So you arrive at the hospital after Christmas. What did you see, and how did you begin your work?
We worked alongside the Palestinian physicians and nurses there, and we really think it’s important to work alongside them and learn from them. We were in one of the last enduring emergency rooms in central Gaza. Within the two weeks that I was there, I saw it go from a semi-functional hospital to a barely or nonfunctional hospital as a result of increasing violence in surrounding areas and, eventually, evacuation notices started coming through.
In the first few hours of my work, I treated an approximately one-year-old boy. His right arm and right leg had been blown off by a bomb, and flesh was still hanging off the foot. He had a bloodstained diaper, which remained, but there was no leg below. I treated the baby while he lay on the ground. There were no stretchers available because all the beds had already been taken, considering that many people were also trying to use the hospital as a shelter or safe space for their families. Next to him there was a man who was on his last breaths. He had been actively dying for the last twenty-four hours, and flies were already on him. All the while, a woman was brought in and was declared dead on arrival. This one-year-old had blood pouring into his chest cavity. He needed a chest tube so he wouldn’t asphyxiate on his own blood. But there were neither chest tubes nor blood-pressure cuffs that were available in pediatric sizes. No morphine had been given in the chaos, and it wasn’t even available. This patient in America would’ve immediately gone to the O.R., but instead the orthopedic surgeon bandaged the stumps up and said he couldn’t take him to the operating theatre right now because there were more pressing emergencies. And I tried to imagine what was more pressing than a one-year-old with no hand and no legs who was choking on his own blood. So that, to me, was symbolic of the impossible choices inflicted on the doctors of Gaza, and how truly cataclysmic that situation is.
Who’s making decisions at the hospital? Are you being told you should do “X,” and someone else should do “Y”? Or it’s just people rushing into rooms, and you are improvising?
So I worked predominantly in the emergency room. I also did work in the pediatric wards. We worked with our MAP colleagues that would help with translation, and then also helped navigate the group work that we would engage in the emergency room. In all honesty, because of the mass casualties, no system is built to withstand that, and so it was truly chaos. So if it’s coming across as chaos, it’s because it was. Because people would come in by any means they could, whether carried on makeshift stretchers, if you’re lucky, or by an ambulance that was overflowing with people, via donkeys. There were bombings happening close by, so you would see the effects of that. So we would work, like I said, alongside the doctors that were able to make it. Many doctors were not able to make it to work because they themselves had been forcibly displaced several times as well.
How many hours per day are you working during these two weeks?
Only during daylight hours, due to security. So 9 A.M. to 3 P.M.
Why only that?
We didn’t feel comfortable. We were staying at a guest house, and we did not feel comfortable with the safety and security measures after dark.
At the hospital, you’re saying?
Both at the hospital and in transit while driving to and from.
Did you feel in some ways that your presence was making a difference in the over-all way in which the hospital functioned? Or was there a sort of sense that you were always so far behind that it was futile?
It’s such a nuanced question. I really appreciate it. I did feel that we were making a difference, and I think the best way I can illustrate that is when Palestinian doctors would look at us as foreign doctors and say, “We’re not forgotten. It’s evidence that they haven’t forgotten us on the outside.” The other way I thought we made a difference was by triaging patients to make room, simply making space in the emergency room, for more patients to come in. So we would be able to see patients and allow the ones who were less urgent to move out of the hospital, so that we could make room for oncoming mass casualties. Doctors sometimes were unable to come. They’re valiantly, bravely looking for shelter for their own families, and showing up to work with a stethoscope the next day, but if they couldn’t make it to work, we were there to fill in some gaps. All that said, it is a completely overwhelming situation in terms of the severity, scale, and magnitude of injuries we were seeing. And no system is designed to withstand that.
You said that things became worse during the two weeks that you were there. Can you describe what changed between the time that you arrived and the time that you left?
Each day became more and more tense, with more and more people piling into surrounding areas looking for safe shelter. I remember I was counselling new mothers on breastfeeding, and I looked out of the ward, and there were plumes of smoke rising in the air and bombs narrowing in on the hospital, and it felt very surreal. One day, a bullet went through the I.C.U. The next day, the road to the hospital had been deemed unsafe for us to use. And then the Israeli military dropped leaflets, designating areas surrounding the hospital as a red zone. Given the history of recent attacks on medical staff and facilities in Gaza, our team was unable to return, and people began evacuating the area in panic.
What do you know about the status of the hospital right now?
I’ve been in touch with the physicians that I worked with. As I mentioned, many are displaced, but they still are turning up to the hospital to try and see patients. There was a period of time when I believe they ran out of fuel. I don’t know if that has been refreshed or not, but all I know is I can’t stop thinking of whether my patients got out, my babies in the neonatal I.C.U. incubators. Who would take care of them? The kids with facial burns: How are they going to be able to see enough, and be well enough to leave? So I don’t know, and I wish I did have more information on that.
Can you talk a little bit about what your life was like in the hours that you were not at the hospital?
The drive from the Rafah border to the guest house is sort of a sea of human tragedy. I have not seen anything as extreme as that, where all people’s worldly items had been packed into cars, or if they were lucky they had cars, or it was a donkey cart, or they were walking barefoot looking for garbage bags to make makeshift tents, looking for wood so that they could find shelter. And there was anything from pets, cats, babies nodding off, and people hanging on the outside of trucks. It was just this less than ten-kilometre drive, if I’m not mistaken, and it took approximately over two hours to get through because everyone was leaving. People had looks of total resignation and abject despair.
In terms of our guest house, we frequently heard bombs, gunfire, air strikes. My door to my balcony didn’t have any glass. It had been blown out. I will say that I was there for two weeks, and people are living in that every day, just to acknowledge my privilege.
Did you have any experience with either Hamas fighters or Israeli forces, in these two weeks?
I could see the Israeli Navy because we would take a coastal road. So I did see them with my own eyes, but I did not otherwise, no.
I am curious if you could talk a little bit about some of the other places that you’ve provided medical care, and compare and contrast them with what you experienced in Gaza.
I was in Afghanistan in 2010, and then 2011, and I had previously been in Gaza, so I feel I can say this about Gaza: Compared to Afghanistan, it was very high capacity, highly educated, with a strong, functioning health-care system that has now been dismantled, whereas in Afghanistan that didn’t exist. It had borne the brunt of war for generations upon generations. If there were no supplies, or if there were no vaccinations, that would not be something new necessarily in many parts of Afghanistan, especially rural Afghanistan, where health care is quite a luxury, as opposed to Gaza. The other notable difference between the two is that I did feel in Afghanistan that hospitals were a safe space in general. I do not feel that with this conflict in particular. I felt in danger at the hospital here.
And what about in comparison to some of the other places you have been?
The other difference I would say is that I’m a pediatrician, so I didn’t expect to be of great use in a war zone. I’m disheartened and really disturbed to say that I had many, many pediatric patients who were war-wounded, burned orphans, traumatic amputations, and that is something different than what I witnessed in Iraq, or elsewhere.
I think the fear among health-care workers was striking. The nature of the burns in the pediatric patients I saw and the severity of the burns I had not witnessed before. Unfortunately, I had seen some burns, but not to that degree, in the U.S. with child-abuse cases. But in Gaza we had charred and blackened burns. And the severity of the traumatic amputations and the frequency with which we saw them.
But the fear among health-care workers themselves of being targeted, of being detained, and the strain upon them as they are trying to do their jobs and take care of their families was never present in other places I have worked in.
We also had a lack of morphine, and ketamine, which we use a lot in pediatrics when we are resetting a bone for example. It provides amnesia so the child doesn’t recall it as a traumatic event. But there was no ketamine at all when I was at the hospital.
I would imagine that, emotionally, there’s a pull to focus all one’s resources on children at a hospital, but I also know that doctors need to do their best to save everyone. I’m just curious how that comes into effect in a situation like what you were a part of.
So the calculus for triage sort of changes, right? I was in Houston during Katrina, and we also saw evacuees. I’ve never equated the two, but I’m just saying that the triage mechanism itself changes to who was most likely to make it, changes to walking wounded, and how we would manage patients. I think that the tendency certainly is to focus on children, but in this context we basically are triaging in an organized chaos in trying to calculate who has the best chance of making it. Because considering supplies are so limited, we want to make sure that our intervention will be what we would call high yield.
What do you mean by high yield?
Maybe concrete examples would work. There’s no portable oxygen, so we need to make sure that whatever oxygen we are giving will be given to people who are most likely to stay alive, and the rest would be palliative comfort care, which is not what you would typically see, perhaps, in American health care. You try and save every single one. But here, if you don’t have the resources, the medicines, the staffing, then you have to triage in a way that prioritizes people who are most likely to live and make a good, solid recovery.
How much did the lack of medicine or the lack of food come up in your daily interactions or your daily life in both cases?
Yeah, the lack of medicines, especially toward the end of my time there, revealed how profoundly ravaged the medical stock and supply system was, and the supply chain. As I mentioned, at the end of our stay, we had no morphine.
Can you talk more about your interactions with Gaza health-care workers?
I think because there were developed relationships thanks to MAP, we were able to work alongside them and had an engendered trust between us. We were leaning on one another, taking and giving orders. We were all on a first-name basis by the end, and leaning on one another’s expertise. They didn’t have tourniquets, and so they were using Foley catheters instead. That was an innovation I learned from. I was the only American physician there, and the remaining ones were British, but we were very much welcome. In Afghanistan, I had the additional layers of being a woman, American, and being of Pakistani origin, and it was much more difficult for me to integrate myself into the health-care system there.
Was this in part because of the historical relationship between Pakistan and Afghanistan?
Absolutely. And also as a woman. In fact, I felt that they were really smart to leverage women in Palestine—in Gaza—when it came to providing privacy and dignity to pregnant women and new moms.
You have given a couple interviews since you have got back. What strategies do you use to talk about what’s happening, while also dealing with emotional stress?
Could you just hold while I compose myself? I tell these stories to elevate the voices of Palestinians that are not getting out. Foreign journalists are not allowed in. Certainly it does affect me. I have seen horrific things throughout my career, and doctors are not great at taking care of themselves. Nor are we encouraged to by our licensing boards. There is a stigma and an entire black market for physicians seeking mental-health care. But I do take that seriously.
One of the ways I am able to compartmentalize or find my way through this complete mess is that I have a daughter of my own, and when I came home I kissed every one of her knuckles and limbs, and listened to her breathe for thirty minutes every night. When I worked in palliative care with kids with cancer I would smell her hair. It is a form of gratitude. She was injured in the Beirut blast as well, so there is a history of trauma and a lot of gratitude around that. But I don’t have an answer. I am still making my way through on how to manage all of this.
What I will say is that I felt much more rewarded and productive in Gaza than I do navigating an American political landscape that may not want to listen to the stories. That is more disheartening and distressing in some ways.
This has been one of the most covered international conflicts, but what is actually different about it than what we’re seeing on the news? How did your perspective change?
There’s nothing that could have prepared me for the horrors that I saw. I think the lack of dignity is intense. I think every single factor of the tapestry of society has been affected: community schools, hospitals, food, and shelter.
And if I could offer an example around how that manifests: a seven-year-old had deep lacerations to his leg and needed some suturing. It wasn’t a life or death case—it was very simple—but the only pain relief we had was Motrin, which was frankly cruel, and a cruel undertaking. There was no ketamine. And so I tried to use one of my pediatric tools as a distraction. And so I had a light flasher, but he wasn’t interested in any of those designs that I put on the wall. So I tried to distract him from the pain. Usually what I would do is ask questions like, “So who’s your best friend?” I can’t ask that because what if his best friend’s dead? “What’s your favorite subject at school?” He hasn’t been to school in three months. “What’s your favorite food?” I don’t know when the last time he ate would be. Every single facet of their society has been ripped apart. ♦
