Women and Children Bear the Brunt of Gaza’s Medical Collapse

Last December, shortly after the weeklong humanitarian pause between Israel and Hamas was lifted, Israeli airstrikes hit the Ed-Durc neighborhood in southern Gaza. Palestinian freelance videographer and photojournalist Montaser al-Sawaf survived the bombing but was severely wounded, according to Turkey-based Anadolu Agency, for whom al-Sawaf had been working at the time. His brother and other family members, however, did not survive. After waiting 30 minutes for an ambulance, al-Sawaf was transported by private vehicle to al-Ahli Baptist Hospital, where he died of his injuries when no medical staff were present to treat him.

Two months earlier, I interviewed al-Sawaf for this story, when the medical catastrophe in Gaza was only beginning to unfold. I remained in contact with him, capturing his on-the-ground perspective of the near-total collapse of Gaza’s health care amid relentless bombardment, until the hour before his death. He is among the nearly 100 journalists and media workers who’ve been killed since October 7, according to the Committee to Protect Journalists, and one of the seven slain Palestinian journalists named in a complaint to the International Criminal Court by Paris-based Reporters Without Borders (RSF) accusing Israeli forces of war crimes for “deliberately targeting” journalists. UNESCO Director-General Audrey Azoulay has called for a “full and transparent investigation” into al-Sawaf’s death.

As of mid-January, not one of Gaza’s 36 hospitals is fully functional, according to the World Health Organization (WHO). Only 11 of them are still operating, at best described as “partially functioning.”

More than 30,000 people have been killed in Gaza since October, when Israel began its siege on the territory in response to the October 7 attacks led by Hamas and other Palestinian Islamist militants that killed more than 1,000 people and abducted more than 200 as hostages. At least 72,000 have been wounded, according to Gaza’s Health Ministry, and an uncountable number are either trapped or already decomposing under the rubble.

While the Ministry’s figures do not distinguish between combatants and civilians, they remain conservative. The full scale of the casualties is yet unknown.

Amid Israel’s retaliatory campaign to wipe Hamas “off the face of the earth,” Gaza’s health care facilities have emerged as active targets of Israeli airstrikes. By early December, at least 364 attacks on health care services had been recorded, leading one UN expert to condemn Israel’s offensive as an “unrelenting war” on Gaza’s health system.

“We are in the darkest time for the right to health in our lifetimes,” said Tlaleng Mofokeng, UN Special Rapporteur on the right to health.

“The medical disaster is very large and indescribable,” Palestinian videographer and photojournalist Montaser al-Sawaf said in Arabic. He’d been documenting the humanitarian crisis from his home in Gaza City since the siege began. When he and other residents were told to evacuate on October 13, al-Sawaf stayed behind to report on the collapse of services at al-Shifa Hospital — the territory’s largest — which became a flashpoint in the crisis last November when Israel’s military raided the medical complex. The operation swiftly drew global outrage, as hundreds of patients and displaced people were already seeking refuge there from bombardment.

“You find patients everywhere in the hospital, in the streets and in public spaces,” al-Sawaf told me in November. “The medical staff is extremely exhausted as they continue day and night for the wounded. There is no time to rest, or a place to sleep.”

The hospital is currently being used as a shelter and cemetery, with only a handful of doctors and nurses left to treat hundreds of patients.

Israel’s government, and its allies in the US intelligence establishment, maintain that Hamas fighters were headquartered under the hospital and potentially held hostages there, but scant evidence has been produced to support their claim of a command center.

During a UN visit to the hospital shortly after the raid, led by the WHO to deliver medicines and surgical supplies, the scene was described as a “bloodbath,” with patients’ injuries stitched on the floor and surgeries performed without pain management — including amputations on children without anesthesia.

Gaza’s population is largely women and children, which means that they make up the majority of patients overflowing these hospitals — as well as the majority of the dead.

Around 70 percent of those killed in the last few months have been women and children, with two mothers killed every hour, and one child estimated to be killed every 10 minutes.

It only took three weeks into the siege for the reported number of children killed to surpass the annual number of children killed across the world’s conflict zones since 2019, Save the Children said in October. Recently, the UN agency for Palestinian refugees (UNRWA) said that more children have been killed in Gaza than in four years of conflict worldwide.

According to Dr. Tanya Haj-Hassan, a pediatric emergency doctor for Médicins Sans Frontières (Doctors Without Borders, or MSF) who has been on several medical missions to Gaza over the past few years, said that the sheer number of child deaths MSF has seen is “unprecedented.”

“[Children] are innocent by any standard,” said Dr. Zaher Sahloul, president and co-founder of MedGlobal, a humanitarian nonprofit that provides emergency response and health programs to vulnerable communities around the world. “By definition, you should not be attacking them.”

The medical situation now, Sahloul said, is the most catastrophic MedGlobal has ever seen in conflict zones.

Gendered violence

The reality for women and girls struggling to survive under active bombardment is its own unique nightmare.

Menstruation may appear as the least of their concerns, but their lack of access to even the most basic reproductive health care has become one of many dire scarcities. Menstrual pads are nearly impossible to come by, and some women have reportedly resorted to creating pads out of old clothes, towels, and the corners of their tents. Many are flocking to hospitals not only for refuge and life-saving care but also to just use the bathroom, which puts them at great risk to do so when hospitals no longer act as the safe zones they once were.

At last look, around 50,000 women in Gaza are pregnant. Premature birth has risen by almost a third, according to Oxfam, and the miscarriage rate has increased by over 300 percent, according to the US-based Center for Constitutional Rights — in an enclave that already had an alarmingly high infant mortality rate.

“There’s no pre-natal care or post-natal care,” said Dr. Thaer Ahmad, an emergency medical physician and MedGlobal board member, who was with Sahloul in Gaza. “There are [displaced] women in tents hoping and relying on a midwife to come there and help with the delivery. If they’re able to make it to a hospital to get a [cesarean section], they have about a handful of hours [before they’re] asked to leave so that bed can be used for somebody else.”

NBC News reported one pregnant woman’s harrowing experience of going into labor shortly after being pulled from the rubble after an Israeli airstrike. She later had an emergency cesarean section in a shelter at a nearby school, where her child was born with a broken leg.

“Put simply,” the UN Population Fund, which works for safe motherhood, said, “if the bombs don’t kill pregnant women, if disease, hunger and dehydration don’t catch up with them — simply giving birth could.”

Children make up nearly half of Gaza’s total population — one of the youngest in the world, NPR reports. But the reason is harrowing: “Many Palestinians simply don’t get the chance to grow old — dying in their early adulthood either in conflicts or due to a struggling health care system — which drags the averages down.”

Decimated care, dire need

Access to medical care was already significantly hindered for Palestinians before last October: In 2001, during what was known as the second Intifada, Israel destroyed Gaza’s only airport, complicating an already strenuous process to obtain the permit needed to seek medical care abroad. Then, in 2007, Israel imposed a land, air, and sea blockade around the enclave, a territory of a mere 140 miles, further impeding access.

Now, with health care facilities, personnel, and rescue workers under siege, Gaza’s health care is “on its knees,” said WHO Director-General Tedros Adhanom Ghebreyesus.

Ahmad, who was deployed to Nasser Hospital in January and was present when it was surrounded by Israeli forces, said that doctors were working 24-hour shifts at the time. “It’s just what they became accustomed to because it depended on what circumstances they were facing that day,” he said. “Was the hospital going to have running water? Were some of the doctors not going to be able to make it that day because it was too dangerous to travel?”

Intensified attacks on and in the vicinity of these hospitals have also forced doctors to make impossible choices: In November, one nurse at al-Nasr Hospital in northern Gaza (not to be confused with Nasser Hospital in the south) made the painful decision to leave behind several babies in the ICU when the complex was forced to evacuate, as there was no way to safely move them. He carried one of them, the one most likely to survive without a respirator, and delivered the infant to an ambulance headed to al-Shifa. The child was one of the premature newborns who captured international attention when that hospital was under fire.

“To leave my patients dying in front of my eyes is the hardest thing I have ever experienced,” the nurse said in a recording obtained by CNN. “It’s indescribable, they broke our hearts, we couldn’t help them, we couldn’t take them, we barely left ourselves with our children, we are civilians, we are a medical crew, we are displaced civilians.”

The babies’ decomposing bodies were later found on the surgical beds they were left on, still attached to wires and feeding tubes.

Irfan Galaria, a Virginia-based plastic and reconstructive surgeon who volunteered for MedGlobal in Gaza in late January, wrote for The Los Angeles Times that local surgeons were now limited, either killed or arrested, their whereabouts unknown. His work “performing 10 to 12 surgeries a day, working 14 to 16 hours at a time,” included performing daily amputations of arms and legs “using a Gigli saw, a Civil War-era tool, essentially a segment of barbed wire,” he said. “Many amputations could’ve been avoided if we’d had access to standard medical equipment.”

Galaria also described treating “a handful of children, all about ages 5 to 8” with sniper shots to their heads. The children were apparently attacked as their families were returning to their homes after Israeli tanks had withdrawn. “But the snipers apparently stayed behind,” he said. “None of these children survived.”

Amid a flood of distressing reports, UN experts last month called on Israel to adopt gender-responsive interventions that prioritize the urgent needs of Palestinian women and girls in Gaza and the West Bank: Among them is a measure to establish a field hospital in Rafah, at the southernmost tip of the territory, “specifically to provide medical assistance for pregnancy and amputations.”

Said the experts: “Implementing these measures would be a long overdue demonstration that Israel cares about the protection of civilians and respects their human rights.”

‘Lost forever’

Although the daily bombardment and ground assault have been the primary cause for the collapse of Gaza’s medical infrastructure, Israel’s blockade of most food, water and fuel entering the territory as aid has caused its own medical crisis, as reports of malnutrition and infectious diseases among Palestinians begins to flourish.

So far, at least 20 people have died of hunger and dehydration — most of them children.

While some mothers are forced to skip meals to feed their children, starving pregnant and breastfeeding mothers simply cannot extricate themselves from their own needs in order to save their babies: Pregnant women have reportedly required emergency surgeries to remove dead fetuses from their wombs after they died of malnutrition and dehydration, while new mothers are unable to produce enough milk to breastfeed, starving many newborns to death. One such case of a day-old baby dying of hunger has already been recorded — the youngest reported death as of this writing.

“In the case of newborn babies, they’re at risk because [they’re] entirely dependent on if a truck with ready-to-use formula is going to cross,” Ahmad said.

“I’m an intensive care doctor, so I do deal with level 1 traumas: Your house gets bombed, you get shot by a sniper, essentially you die a rapid death that is extremely traumatic, as I have seen,” said Haj-Hassan. “But then you have slow death, which is starvation, severe acute malnutrition, epidemics, and disease. It’s this vicious cycle where they’re getting sick because they don’t have access to normal water and sanitation practices. Then, they get sick and don’t have access to health care facilities to get better.”

Doctors are not exempt, either. One displaced health worker in Rafah told CNN that his friend, a doctor at al-Awda Hospital in northern Gaza, was unable to treat wounded patients due to his own exhaustion from hunger.

Most aid trucks are stuck at the border with Egypt due to lengthy inspections, but the Israeli military has also opened fire numerous times on those trying to retrieve this aid from trucks that have made it through, or the aid airdropped into the sea. In February, the World Food Program briefly suspended its aid into Gaza after an airstrike hit one of their delivery trucks. Recently, Israeli forces struck a UN food distribution center, killing one staffer and injuring 22 others. Israeli protesters, too, have attacked aid trucks, some believing that preventing food and supplies will force Hamas to release the remaining hostages.

A recent report by Refugees International said that Israel’s obstruction of aid has generated “famine-like conditions” for the entire territory, noting that those conditions are now “apocalyptic.”

The European Union’s high representative for foreign affairs Josep Borrell recently described the blockade as a weapon of war. “Starvation is being used as a war arm,” he told the UN Security Council. “And when we condemned this happening in Ukraine, we have to use the same words for what is happening in Gaza.”

Although women and children have been disproportionately impacted over the last five months, Loubna Qutami, a member of the Palestinian Feminist Collective, said it is just as important to acknowledge that the violence in Gaza is targeting everyone.

“Decolonial feminist thought and practice has always fundamentally been about the right to life and the necessity to create, protect, and defend it when it is under attack,” she said. “As we grieve and advocate for women and children, and address the specific ways they are experiencing harm, we also must not erase the grief, pain, and murder of Palestinian men, which the media has endlessly vilified to justify this genocide.”

The pronounced suffering of the Palestinian civilian population has been made more acute by the collapse of health care in Gaza, but an invisibilized dimension of that suffering, which has yet to be broached, is the psychological toll of surviving while surrounded by mass death.

When Al Jazeera reporters asked a 16-year-old girl, who fled south without her family, what she thought about the most, the child responded, “death.”

“It’s tough to gauge, but nearly every person in Gaza has a story of a loved one killed, a home destroyed, a family separated,” said Ahmad. “They’re in survival mode, and they’re prioritizing their immediate critical needs.”

Ahmad said that for those trying to survive amid imminent famine, bombardment, displacement, and fear for themselves and their loved ones, their mental health is hardly top of mind. This, too, comes with devastating consequences.

“How do you communicate with a child who is mute because they have, in front of their eyes, seen some — or all — members of their family massacred?” Haj-Hassan said. “And I don’t just mean lost forever. I also mean the images in their head of dismembered dead family members. I don’t know how you overcome that in the long run, but in the short run you have to deal with a child who won’t talk, who won’t eat and drink.”

It’s an important question, Qutami agreed, but one that simply cannot be addressed at present. “Ultimately, healing processes and repair cannot happen while the bombs are still dropping.”

Despite international pressure to halt an assault on Rafah, where more than 1.5 million displaced Palestinians are sheltering, Israeli Prime Minister Benjamin Netanyahu vowed to press forward. The MSF team in Rafah has said that medical humanitarian activities consequently would be “almost-impossible to sustain,” with or without warnings to evacuate elsewhere.

As Ramadan, a month of religious devotion and dawn-to-dusk fasting, also begins, Palestinian families in Gaza continue facing famine and loss as they wait for a ceasefire.

Montaser al-Sawaf in life

“Montaser was one of those people who was passionate about his work,” Sawaf’s cousin, Rewaa, told me. “He was interested in conveying the truth and a clear picture about Palestine.”

Rewaa remembers how her cousin would pick figs and grapes from neighboring orchards during the summer months and share the harvest with family, friends, and community members. He was nothing but compassionate and considerate, she said.

“Since his childhood, he has always been generous and loved to serve others,” said Rewaa. “In the last days before the war, he used to make handmade necklaces and bracelets at home for the children to bring them joy and happiness.”

In the daily conversations al-Sawaf and I would have, it felt unavailing to ask how he was doing. He had been through many wars here, but, he admitted, this was the most horrific and numbing. Before his passing, al-Sawaf spoke about what living — and dying — under bombardment felt like.

“We find our relatives, friends and family as martyrs, and hours and days pass without much feeling,” al-Sawaf said in November. As for our situation right now, we have become without any feelings.”

Al-Sawaf was laid to rest at the al-Batsh cemetery.