The Geographies of Sixty Minutes

One of the cardinal principles informing modern casualty evacuation is the Golden Hour.  In 1975 R. Adams Cowley, founder of Baltimore’s Shock Trauma Institute, argued that ‘the first hour after injury will largely determine a critically injured person’s chances for survival.’  It’s not a straightforward metric, and combat medical care and evacuation has been transformed since it was first proposed, but the rule of thumb is that the chances of survival are maximised if the time between traumatic injury and definitive care is kept to 60 minutes or less.

Following a fire-storm of criticism on 15 June 2009 US Secretary of Defense Robert Gates required the standard time between a call for evacuation and treatment of the critically injured to be 60 minutes or less.  For US military personnel in the Second World War the average time was 10 hours; in Korea that had been cut to 5 hours (the result of using helicopters for speedy evacuation); and in Vietnam it was already down to one hour.  The reason for Gates’s intervention was that in Afghanistan the aim was two hours…

U.S. Air Force Sgt. Daniel Fye serving on a tour in the Kandahar province of Afghanistan in April 2011. (Courtesy of Daniel Fye)

U.S. Air Force Sgt. Daniel Fye serving on a tour in the Kandahar province of Afghanistan in April 2011. (Courtesy of Daniel Fye)

The importance of those time-critical sixty minutes was no secret to the troops in the line of fire.  Here is a scene from Brian Castner‘s truly brilliant All the ways we die and kill which imagines the thoughts running through one soldier’s head – Air Force Technical Sergeant Dan Fye on his third tour of duty with Explosive Ordnance Disposal (above) – after he stepped on an IED during a clearance operation in Mushan (Panjwayi) on 27 May 2011:

They worked on Fye a long time, and the longer they worked, the more anxious Fye got about the precious minutes slipping away. “I don’t hear the bird,” he said, over and over. They wrote the time of the tourniquet application on the white headband Fye wore under his helmet. Hopkins pushed morphine into his veins.

Eventually, an eon since Hopkins arrived but only twenty-five minutes after the blast, the hyperactive thump of helo blades cutting air slowly emerged in the distance.

Fye thought it was the most wonderful sound he had ever heard. They were at the extreme limit of the NATO footprint, and so it was a sixty-kilometer flight to the main hospital at Kandahar [see map below]. If they moved quickly, Fye would just make it in the magic golden hour.

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Castner writes that as Fye was bleeding out in the back of the helicopter, he was

‘clinging to one thought and one thought only, running in a continuous Times Square news ticker across the front of his oxygen-starved brain: One hour. If I can get back to Kandahar in one hour, I’ll live. One hour, and I’ll live. That’s what they say. You’ll make it if you can get back to the hospital in one hour.’

He made it.  The new, modernised and expanded Role 3 NATO hospital at Kandahar had opened a year earlier, and its executive officer claimed that ‘They hit our doors, they live.’

Kandahar new Role 3 2010

But Fye was lucky.  Later he learned why it had taken so long for the helicopter to arrive, and why he very nearly never made it to Kandahar at all:

Over multiple radio calls between Hopkins’s platoon and the rescue operations center, his report of “bilateral amputation” had been converted, telephone-game style, into “bilateral lacerations.” The medical operations center had actually turned the rescue mission off; helos don’t fly for scraped knees. The bird that eventually picked up Fye wasn’t even a real medevac bird. That’s why the robotic flight crew ignored him, didn’t treat his wounds as they went. They weren’t medics. The helo pilots had just been in the air and happened to overhear the radio traffic, including the original call for help. They understood the mistake and had disobeyed orders to go get Fye. If the human pilot of that bird had been less stubborn, the golden hour would have been long past by the time Fye made it to KAF, and he could well have been one of the 1 percent.

(More from Brian on medical evacuation here and here).

Even without miscommunication the logistical challenges were formidable.  In 2007, two years before Gates’ intervention, ISAF produced this map showing the medevac coverage – what Fye called the ‘NATO footprint’ – that supported that two-hour standard (I have taken this map and the following one from a report prepared by Col Dr Ingo Hartenstein for NATO/ISAF in December 2008 which is available here; scroll down):

ISAF Medevac coverage 2 hours

Like Vietnam, Afghanistan was a ‘war without fronts’ with a battlefield geometry that imposed a radically different evacuation model from the classical line of evacuation that had been established during the First World War.  Here is how Brian Turner puts it in My life as another country:

We won’t hear the battle in progress and work our way toward it as baggage trains of wounded, exhausted soldiers and civilians carrying their lives on their backs travel in the opposite direction. Our battle space – and perhaps it’s a cliché now – will occur in a 360-degree, three-dimensional environment.

More technically, here is Brigadier Martin Bricknell, who served (among many other roles) as Medical Adviser to ISAF’s Regional Command South in Kandahar in 2010:

The tactical geometry for the current operating environment is based upon security forces holding areas of ground and securing this space from opposition activity. This converts the battlefield from the conventional force-on-force linear geometry with an identifiable confrontation line to an area battlefield with multiple nodes of contested space. Thus the MEDEVAC mission is converted from a linear flow to area support, hence MEDEVAC planning is based upon a ‘range ring’ coverage with a radius of 40–60 nautical miles.

Given the available resources, a second map showed how those ‘range rings’ would contract if the Golden Hour were to be imposed over the evacuation grid:

ISAF MEDEVAC coverage allowing 1 hr from POI to surgery HARTENSTEIN

In practice, the situation was more variable than these maps imply – not least because there was a significant difference between the ways in which American and British contingents organised medical evacuation.

The US military, drawing on their experience in Vietnam, used Blackhawk or Pavehawk helicopters to get paramedics or combat medical technicians to the casualty as fast as possible:

DUST OFF Afghanistan.001

DUST OFF Afghanistan.002

The British used larger Chinook helicopters to dispatch a Medical Emergency Response Team (MERT) with a trauma surgeon onboard to the casualty close to the point of injury (POI):

MERT Afghanistan.001

The response time was usually longer but the MERT enabled advanced trauma care to begin as soon as the patient was onboard.

There has been considerable debate and disagreement about the robustness of the ‘Golden Hour’ in military trauma care and its relation to evacuation pathways: see, for example,  Jonathan Clarke and Peter Davis, ‘Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010-April 2011’, Military Medicine 171 (11) (2012) 1261-6.  But a research team has now calibrated the effects of reduced evacuation time on US casualty fatality rates (CFR) in Afghanistan between 2001 and 2014 [Russ Kotwal et al, ‘The effect of a Golden Hour policy on the morbidity and mortality of combat casualties’, JAMA Surgery 151 (1) (2016) 15-24; see also here]:

KOTWAL Case fatality rate and transport time

For 4,500 cases of US military casualties with detailed data the study showed a substantial change in the CFR following the Secretary of Defense’s mandate to evacuate casualties within 60 minutes: as the median evacuation time fell from 90 minutes to 43 minutes the CFR fell from 13.7 to 7.6; before the mandate 25 per cent of casualty evacuation missions fell within the Golden Hour, after the mandate the proportion soared to 75 per cent.

The interpretive field is a complicated one – while a significant number of casualties who would previously have died from their wounds now survived, a proportion of those who would previously have been recorded as ‘killed in action’ (KIA) none the less now ‘died of wounds’ (DOW) – and the reasons for the improvement in survival rates are also multivariate:

‘Secondary effects resulting from the mandate that contributed to achieving the mandated time included stream-lined authority and helicopter launch procedures, increased number and dispersion of Army helicopters, and the addition of Air Force helicopters to assist with the Army prehospital transport mission. As decreased time from critical injury to treatment capability was the underlying goal, personnel with increased expertise (blood transfusion protocol-trained basic medics, critical care paramedics, and critical care nurses) were trained and assigned to prehospital flights more routinely, resulting in earlier availability of blood products and other advanced care.

In addition, an increase in the number and dispersion of small but mobile forward surgical teams across the battle-field brought major surgical capability even closer to the point of injury and provided an alternative to transporting patients longer distances to large, but less mobile, civilian trauma center–equivalent [Combat Support Hospitals].’

GoldenHourFig1

These findings – together with the experience of the British MERTs – intersect with a recalibration of the Golden Hour.  The US Combat Casualty Care Research Program (CCCRP) has proposed an ‘evolved concept’ (see the figure above) that moves from a location-based protocol to a physiological one:

The program must be willing to turn the doctrine of fixed or traditional echelons of care on its side and innovate for scenarios in which Level II and III care is performed aboard transport vehicles (land-, air- or sea-based) or within local structures of opportunity. In such circumstances, field care may be prolonged, lasting for days or even weeks. Combat casualty care research with these complex scenarios in mind promises to enhance resuscitative capability for injured service personnel regardless of environment, leveraging communications networks (i.e., telementoring) and targeted resupplies of materials. In the future, CCCRP must focus on transforming the concept of the golden hour into one bound not by the time to reach traditional echelons of care or fixed facilities, but the time until enhanced resuscitative capability can be delivered to the injured troop, regardless of location or need for transport.

There are two riders to add.  First, embedded within the Golden Hour are ‘the platinum ten minutes’: the imperative to stop bleeding (which has led to the re-emergence and re-engineering of the tourniquet) and to control the casualty’s airway within 10 minutes of wounding.

Combat Medical Technician and Platinum 10 minutes.001

The second is that the speed of treatment and trauma care available to American and British soldiers is radically different from that available to Afghan soldiers and police officers.  Previously, they could rely on aeromedical evacuation by their allies.  But now most of their medical evacuations take place by land, over difficult and dangerous roads.  Last September Josh Smith reported:

Under the dim light of a single bulb, a local Afghan policeman lay severely injured, slipping in and out of consciousness. A military doctor reported to an Afghan army brigade commander that the man was unlikely to live through the night.

Injured Afghan policeman examined by Afghan Army doctor August 2015

Despite the doctor’s pleas, the commander stood firm. The army could not spare any soldiers or ambulances [below] to make the five-hour drive to a better hospital at that late hour through territory teeming with Taliban ambushes and roadside bombs.

, Nangarhar province, August 2015

The lack of speedy evacuation is a tragically common problem for the rising number of Afghan police and soldiers being injured on the battlefields of Afghanistan. U.S. advisers have worked to help close the capability gap, but mostly behind the scenes, far from the battlefields where many Afghan troops say they increasingly feel alone.

Although the American forces still stationed in the country have conducted more than 200 airstrikes since their combat mission was declared over at the end of 2014, as of July, U.S. military aircraft had not flown a single conventional medical evacuation mission, according to data released by the U.S. Air Force Central Command.

U.S. military officials say they haven’t flown evacuation missions because they haven’t been asked. Also, there are far fewer American resources available for such missions now.

The difference shows up in the ratios of those killed and those who survived their wounds.

About 2,363 Americans have died in Afghanistan, with a little more than 20,000 wounded, a ratio of roughly 1-to-10.  In the first half of 2015 alone, 4,302 Afghan soldiers and police were killed in action and 8,009 more were wounded, a ratio of about 1-to-2.

Even where aircraft and trained medical technicians are available, Jeff Schogol found that the Afghan capability falls well outside the Golden Hour:

The time it takes to fly patients to hospitals varies depending on the point of injury, but it can take between 90 minutes and two and a half hours to fly an aeromedical evacuation mission in a C-208, plus one hour to transfer patients from Kandahar to Kabul in a C-130.

Injured ANA soldier lifted from Afghan Air Force C-27A

And the situation for Afghan civilians – as I explored in detail in ‘The prosthetics of military violence‘ – is still worse.

This is not a problem confined to Afghanistan: think of how the possibility of the Golden Hour recedes in urban combat zones subjected to artillery fire and bombing – the difficulties faced by first responders in Gaza or in the ravaged, rubble-strewn towns and cities of Syria (see also Annie Sparrow‘s report here).

 A Syrian youth walks past a destroyed ambulance in the Saif al-Dawla district of the war-torn northern city of Aleppo on January 12, 2013. An accident and emergency centre in Aleppo uses an abandoned supermarket to conceal a fleet of 16 ambulances, just 10 of which are in working order and are driven by 22 staff members. AFP PHOTO/JM LOPEZ/ (Getty Images)


A Syrian youth walks past a destroyed ambulance in the Saif al-Dawla district of the war-torn northern city of Aleppo on January 12, 2013. An accident and emergency centre in Aleppo uses an abandoned supermarket to conceal a fleet of 16 ambulances, just 10 of which are in working order and are driven by 22 staff members. AFP PHOTO/JM LOPEZ/ (Getty Images)

And there is no guarantee of safety even once casualties reach hospital since the principle of medical neutrality is now being routinely and systematically violated.

Gaza 101

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101 is the emergency number for Gaza and the rest of occupied Palestine.  And perhaps I should begin with that sentence: I say ‘the rest of occupied Palestine’ because, despite Israel’s ‘disengagement’ from Gaza in 2005, Israel continues to exercise effective control over the territory which means that Gaza has continued to remain under occupation.  It’s a contentious issue – like Israel’s duplicitous claim that the West Bank is not ‘occupied’ either (even by its illegal settlers) merely ‘disputed’ – and if you want the official Israeli argument you can find it in this short contribution by a former head of the IDF’s International Law Department here and here.  The value of that essay – apart from illustrating exactly what is meant by chutzpah – is its crisp explanation of why the issue matters:

‘This does not necessarily mean that Israel has no legal obligations towards the population of the Gaza Strip, but that to the extent that there are any such legal obligations, they are limited in nature and do not include the duty to actively ensure normal life for the civilian population, as would be required by the law of belligerent occupation…’

Certainly, one of the objectives of Israel’s ‘disengagement’ was to produce what its political and military apparatus saw as ‘an optimal balance between maximum control over the territory and minimum responsibility for its non-Jewish population’.  That concise formulation is Darryl Li‘s, which you can find in his excellent explication of Israel’s (de)construction of Gaza as a ‘laboratory’ for its brutal bio-political and necro-political experimentations [Journal of Palestine Studies 35 (2) (2006)]. (Another objective was to freeze the so-called ‘peace process’, as Mouin Rabbani explains in the latest London Review of Books here; his essay also provides an excellent background to the immediate precipitates of the present invasion). Still, none of this entitles Israel to evade the obligations of international law.  Here it’s necessary to recall Daniel Reisner‘s proud claim that ‘If you do something for long enough, the world will accept it… International law progresses through violations’: Reisner also once served as head of the IDF’s International Law Department, and the mantra remains an article of faith that guides IDF operations.  But as B’Tselem, the Israeli Information Center for Human Rights in the Occupied Territories, insisted in an important opinion published at the start of this year:

Even after the disengagement, Israel continues to bear legal responsibility for the consequences of its actions and omissions concerning residents of the Gaza Strip. This responsibility is unrelated to the question of whether Israel continues to be the occupier of the Gaza Strip.

But there’s more.  International humanitarian law – no deus ex machina, to be sure, and far from above the fray – not only applies during Israel’s military offensives and operations, including the present catastrophic assault on Gaza, but provides an enduring set of obligations.  For as Lisa Hajjar shows in a detailed discussion re-published by Jadaliyya last week, Israel’s attempts to make Gaza into a space of exception – ‘neither sovereign nor occupied’ but sui generis – run foul of the inconvenient fact that Gaza remains under occupation. Israel continues to control Gaza’s airspace and airwaves, its maritime border and its land borders, and determines what (and who) is allowed in or out [see my previous post and map here].  As Richard Falk argues, ‘the entrapment of the Gaza population within closed borders is part of a deliberate Israeli pattern of prolonged collective punishment’ – ‘a grave breach of Article 33 of the Fourth Geneva Convention’ – and one in which the military regime ruling Egypt is now an active and willing accomplice.

Karam abu Salem crossing

So: Gaza 101.  Medical equipment and supplies are exempt from the blockade and are allowed through the Karam Abu Salem crossing (after protracted and expensive security checks) but the siege economy of Gaza has been so cruelly and deliberately weakened by Israel that it has been extremely difficult for authorities to pay for them.  Their precarious financial position is made worse by direct Israeli intervention in the supply of pharmaceuticals.  Corporate Watch reports that

When health services in Gaza purchase drugs from the international market they come into Israel through the port of Ashdod but are not permitted to travel the 35km to Karam Abu Salem directly. Instead they are transported to the Bitunia checkpoint into the West Bank and stored in Ramallah, where a permit is applied for to transport them to Gaza, significantly increasing the length and expense of the journey.

There’s more – much more: you can download the briefing here – but all this explains why Gaza depends so much on humanitarian aid (and, in the past, on medical supplies smuggled in through the tunnels).  Earlier this summer Gaza’s medical facilities were facing major shortfalls; 28 per cent of essential drugs and 54 per cent of medical disposables were at zero stock.

ochaopt_atlas_health_care_december2011

Medical care involves more than bringing in vital supplies and maintaining infrastructure (the map of medical facilities above is taken from the UN’s humanitarian atlas and shows the situation in December 2011; the WHO’s summary of the situation in 2012 is here).  Medical care also involves unrestricted access to electricity and clean water; both are compromised in Gaza, and on 1 January 2014 B’Tselem reported a grave deterioration in health care as a result:

‘The siege that Israel has imposed on the Gaza Strip since Hamas took over control of the security apparatus there in June 2007 has greatly harmed Gaza’s health system, which had not functioned well beforehand…. The reduction, and sometimes total stoppage, of the supply of fuel to Gaza for days at a time has led to a decrease in the quality of medical services, reduced use of ambulances, and serious harm to elements needed for proper health, such as clean drinking water and regular removal of solid waste. Currently, some 30 percent of the Gaza Strip’s residents do not receive water on a regular basis.’

WHO Right to healthIn-bound transfers are tightly constrained, but so too are out-bound movements.  Seriously ill patients requiring advanced treatment had their access to specialists and hospitals outside Gaza restricted:

‘Israel has cut back on issuing permits to enter the country for the hundreds of patients each month who need immediate life-saving treatment and urgent, advanced treatment unavailable in Gaza. The only crossing open to patients is Erez Crossing, through which Israel allows some of these patients to cross to go to hospitals inside Israel [principally in East Jerusalem], and to treatment facilities in the West Bank, Egypt, and Jordan. Some patients not allowed to cross have referrals to Israeli hospitals or other hospitals. Since Hamas took over control of the Gaza Strip, the number of patients forbidden to leave Gaza “for security reasons” has steadily increased.’

As in the West Bank, Israel has established a labyrinthine system to regulate and limit the mobility of Palestinians even for medical treatment.  Last month the World Health Organization explained the system and its consequences (you can find a detailed report with case studies here):

‘In Gaza, patients must submit a permit application at least 10 days in advance of their hospital appointment to allow for Israeli processing. Documents are reviewed first by the health coordinator but final decisions are made by security officials. Permits can be denied for reasons of security, without explanation; decisions are often delayed. In 2013, 40 patients were denied and 1,616 were delayed travel through Erez crossing to access hospitals in East Jerusalem, Israel, the West Bank and Jordan past the time of their scheduled appointment. If a patient loses an appointment they must begin the application process again. Delays interrupt the continuity of medical care and can result in deterioration of patient health. Companions (mandatory for children) must also apply for permits. A parent accompanying a child is sometimes denied a permit, and often both parents, and the family must arrange for a substitute, a process which delays the child’s treatment.’

On 17 June Al-Shifa Hospital, the main medical facility in Gaza City (see map below), had already been forced to cancel all elective surgeries and concentrate on emergency treatment.  On 3 July it had to restrict treatment to life-saving emergency surgery to conserve its dwindling supplies. All of this, remember, was before the latest Israeli offensive.  People have not stopped getting sick or needing urgent treatment for chronic conditions, so the situation has deteriorated dramatically.  The care of these patients has been further compromised by the new, desperately urgent imperative to prioritise the treatment of those suffering life-threatening injuries from Israel’s military violence.

al-Shifa and Shuja'iyeh map

Trauma surgeons emphasise the importance of the ‘golden hour’: the need to provide advanced medical care within 60 minutes of being injured.  Before the IDF launched its ground invasion, there were three main sources of injury: blast wounds from missiles, penetrating wounds from artillery grenades and compression injuries from buildings collapsing.  But this is only a typology; many patients have multiple injuries. ‘We are not just getting patients with one injury that needs attending,’ said the head of surgery at Al-Shifa, ‘we are getting a patient with his brain coming out of his skull, his chest crushed, and his limbs missing.’  All of these injuries are time-critical and require rapid intervention. Ambulance control centre central GazaAnd yet the Ministry of Health reckons that Gaza’s ambulance service is running at 50 per cent capacity as a result of fuel shortages.  That figure must have been reduced still further by the number of ambulances that have been hit by Israeli fire (for more on paramedics in Gaza, and the extraordinary risks they run making 20-30 trips or more every day, see here and this report from the Telegraph‘s David Blair here).  When CNN reporters visited the dispatch centre at Jerusalem Hospital in Gaza City last Tuesday, they watched a a screen with illuminated numbers recording 193 killed and 1,481 injured and the director of emergency services dispatching available ambulances to the site of the latest air strike (by then, there had already been over 1,000 of them).  But the system only works effectively when there is electricity…

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Power supplies were spasmodic at the best of times (whenever those were); they have been even more seriously disrupted by the air campaign, and since the start of the ground assault Gaza has lost around 90 per cent of its power generating capacity.  Nasouh Nazzal reports that many hospitals have been forced to switch to out-dated generators to light buildings and power equipment:

“The power generators in Gaza hospitals are not trusted at all and they can go down any moment. If power goes out, medical services will be basically terminated,” [Dr Nasser Al Qaedrah] said. He stressed that the old-fashioned types of power generators available in Gaza consume huge quantities of diesel, a rare product in the coastal enclave.

On occasion, Norwegian ER surgeon Mads Gilbert told reporters, if the lights go out in the middle of an operation ‘[surgeons] pick up their phones, and they use the light from the screen to illuminate the operation field.’ (He had brought head-lamps with him from Bergen but found they were on Israel’s banned list of ‘dual-use’ goods). As the number of casualties rises, the vast majority of them civilians, so hospitals have been stretched to the limit and beyond.  According to Jessica Purkiss, the situation was already desperate a week ago:

“The number of injuries is huge compared to the hospitals’ capacity,” said Fikr Shalltoot, the Gaza program director for Medical Aid for Palestinians, an organization desperately trying to raise funds to procure more supplies. “There are 1,000 hospital beds in the whole of Gaza. An average of 200 injuries are coming to them every day.”

As in so many other contemporary conflicts – Iraq, Libya, Syria – hospitals themselves had already become targets for military violence.  For eleven days Al-Wafa Hospital in Shuja’iyeh in eastern Gaza City (see the map above), the only rehabilitation centre serving the occupied territories, was receiving phone calls from the IDF warning them that the building was about to be bombed.  [In case you’re impressed by the consideration, think about Paul Woodward‘s observation: ‘I grew up in Britain during the era when the Provisional IRA was conducting a bombing campaign in Northern Ireland and on the mainland. I don’t remember the Provos ever being praised for the fact that they would typically phone the police to issue a warning before their bombs detonated. No one ever dubbed them the most humane terrorist organization in the world.’] The staff refused to evacuate the hospital because their patients were paralysed or unconscious. The Executive Director, Dr Basman Alashi, explained:

‘We’ve been in this place since 1996. We are known to the Israeli government. We are known to the Israeli Health Center and Health Ministry. They have transferred several patients to our hospital for rehabilitations. And we have many success stories of people come for rehabilitation. They come crawling or in a wheelchair; they go out of the hospital walking, and they go back to Israel saying that al-Wafa has done miracle to them. So we are known to them, who we are, what we are. And we are not too far from their border. Our building is not too small. It’s big. It’s about 2,000 square meters. If I stand on the window, I can see the Israelis, and they can see me. So we are not hiding anything in the building. They can see me, and I can see them. And we’ve been here for the last 12 or 15 years, neighbors, next to each other. We have not done any harm to anybody, but we try to save life, to give life, to better life to either an Arab Palestinian or an Israeli Jew.’

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But just after 9 p.m. on 17 July shells started falling:

‘… the fourth floor, third floor, second floor. Smoke, fire, dust all over. We lost electricity… luckily, nobody got hurt. Only burning building, smoke inside, dust, ceiling falling, wall broke, electricity cutoff, water is leaking everywhere. So, the hospital became [uninhabitable].’

Seventeen patients were evacuated and transferred to the Sahaba Medical Complex in Gaza City. Sharif Abdel Kouddos takes up the story:

‘The electricity went out, all the windows shattered, the hospital was full of dust, we couldn’t see anything,’ says Aya Abdan, a 16-year-old patient at the hospital who is paraplegic and has cancer in her spinal cord. She is one of the few who can speak.

It is, of course, literally unspeakable.  But this was not an isolated incident – still less ‘a mistake’ – and other hospitals have been bombed or shelled.  According to the Ministry of Health, 25 health facilities in Gaza have been partially or totally destroyed. Just this morning it was reported that Israeli tanks shelled the al-Aqsa Hospital in Deir al-Balah in central Gaza, killing five and injuring 70 staff and patients. The Guardian reports that ambulances which tried to evacuate patients were forced to turn back by continued shelling.  According to Peter Beaumont:

‘”People can’t believe this is happening – that a medical hospital was shelled without the briefest warning. It was already full with patients,” said Fikr Shalltoot, director of programmes at Medical Aid for Palestinians in Gaza city.’

mads-gilbert-at-al-shifa-hospital

The hospitals that remain in operation are overwhelmed, with doctors making heart-wrenching decisions about who to treat and who to send away, refusing ‘moderately injured patients they normally would have admitted in order to make room for the more seriously wounded.’  Mads Gilbert (centre in the image above) again:

Oh NO! not one more load of tens of maimed and bleeding, we still have lakes of blood on the floor in the ER, piles of dripping, blood-soaked bandages to clear out – oh – the cleaners, everywhere, swiftly shovelling the blood and discarded tissues, hair, clothes,cannulas – the leftovers from death – all taken away…to be prepared again, to be repeated all over. More then 100 cases came to Shifa last 24 hrs. enough for a large well trained hospital with everything, but here – almost nothing: electricity, water, disposables, drugs, OR-tables, instruments, monitors – all rusted and  as if taken from museums of yesterdays hospitals.

Al-Shifa, where he is working round the clock, has only 11 beds in its ER and just six Operating Rooms.  On Saturday night, when the Israeli army devastated the suburb of Shuja’ieyh, its ‘tank shells falling like hot raindrops‘, al-Shifa had to deal with more than 400 injured patients. Al-Shifa is Gaza’s main trauma centre but in other sense Gaza’s trauma is not ‘centred’ at all but is everywhere within its iron walls.  Commentators repeatedly describe Gaza as the world’s largest open-air prison – though, given the cruelly calculated deprivation of the means of normal life, concentration camp would be more accurate – but it is also one where the guards routinely kill, wound and hurt the prisoners. The medical geography I’ve sketched here is another way of reading Israel’s bloody ‘map of pain‘. I am sickened by the endless calls for ‘balance’, for ‘both sides’ to do x and y and z, as though this is something other than a desperately unequal struggle: as though every day, month and year the Palestinians have not been losing their land, their lives and their liberties to a brutal, calculating and manipulative occupier.  I started this post with an image of a Palestinian ambulance; the photograph below was taken in Shuja’ieyh at the weekend.  It too is an image of a Palestinian ambulance.

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For updates see here; I fear there will be more to come. In addition to the links in the post above, this short post is also relevant (I’ve received an e-mail asking me if I realised what the initial letters spelled…. Duh.)