Inside a Gaza IMC Field Hospital—Gaza: The Human Toll

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This transcript is from a CSIS event hosted on March 25, 2024. Watch the full video here.

J. Stephen Morrison: Hello and good morning, good evening, good afternoon. I’m J. Stephen Morrison. I’m senior vice president here at the Center for Strategic and International Studies, CSIS, based in Washington, D.C. Today’s the 9th episode of the CSIS video broadcast series, “Gaza: The Human Toll.” It’s a product of the CSIS Bipartisan Alliance for Global Health Security, in partnership with our colleges here at CSIS at the Humanitarian Agenda Program and the Middle East Program.

I want to offer special thanks today to the many colleagues and friends who’ve supported us. As we’ll see, today we’re going to introduce a lead-in video. I’ll say a bit more about that in a moment. We’re particularly indebted to Shams Odeh, Justin Kenny, and Paul Franz for our ability to pull this film together, shot inside Gaza just recently – in the recent days. I want to also offer special thanks to Sophia Hirshfield, my colleague in the alliance, for coordinating all of the aspects of this production. To Eric Ruditskiy and Qi Yu on our famous production team here. I want to also offer thanks to Todd Bernhardt from the International Medical Corps.

As we’ll see in a moment, we’ll be hearing from Dr. Zawar Ali, who is the team lead in Cairo and the medical advisor for the IMC field hospital. He works with the International Medical Corps. Went into Rafah January 1st to set up the field hospital. We’ll be hearing much more from him. The field hospital figures in the video that we’re going to show you to lead off this hour. Dr. Zawar Ali is a physician and senior specialists with International Medical Corps in Pakistan. Went in January 1st, became – the field hospital became operational three days later. He stayed until the early part of February, and will be returning again from Cairo. Oversees the resupply, and coordination, and operations of that very important field hospital in Rafah.

Our second keynote guest is a friend who’s appeared and been very generous to us in earlier episodes, and that is Rik Peeperkorn. He joined in March 2021 when he was appointed as the WHO representative in WHO’s Office for the West Bank and Gaza. He’s the representative for Occupied Palestinian Territory. He’s appeared on several earlier episodes of this series. And we’re very grateful that he’s making the time.

Obviously, this is – remains a fraught period. Looming over – looming over every conversation is the threat of the seizure of Rafah. We have senior Israeli officials here this week for discussions around that, and what that might mean, and how to think about the looming humanitarian catastrophe of 1.5 million displaced in Rafah. We have increased discussions around the specter of famine and mass starvation in Gaza, concentrated in the worst forms in northern Gaza but, as we’ll hear, malnutrition – severe malnutrition affecting larger populations across the territory. And also fear of infectious epidemic disease, diseases and rising excess mortality. Along with the efforts still underway to find some kind of peace accord that would bring a pause to the fighting and to easing of the humanitarian situation and release of hostages, prisoners, and detainees.

Today, we have a four-and-a-half-minute video that we produced from within Gaza. We’re going to go straight to that video, watch that, and then immediately afterwards we will hear from Dr. Ali, followed by Dr. Peeperkorn. So if we could tee up that film right now, thank you.

(A video presentation begins.)

(Translated from Arabic.) Since the beginning of this aggression, there has been no protection for medical teams in the Gaza Strip and our medical teams in the health sector have been targeted.

We are now on the 165th day in a row without enough electricity, without potable water, and without food supplies. Even us, in this hospital, cannot provide any meals to any patients due to the lack of food supplies. As for the aid that reaches this hospital, it only meets 3 percent of the needs of this hospital.

We always thank God that there are institutions like this hospital receiving patients, chronic and emergency patients.

I was sitting in the Red Crescent. There was shooting. Soldiers were sitting on top of the buildings there. They shot three people in front of the door of the Red Crescent. I went out of the Red Crescent to save one of them. When I came out, I bowed down to carry a dead body of someone killed. As I moved my arm, I was hit by a bullet.

The medical situation in the Gaza Strip at the current time is bad and getting worse day after day.

We see ourselves working like we’re carving stone. The medical tests are nonexistent and there is very little medication. The medical situation in Gaza is a total disaster.

(Video presentation ends.)

Dr. Morrison: Thank you to the International Medical Corps for its support in putting this video together.

Thank you, Dr. Ali, for being with us and for your leadership role in establishing this field hospital, and your continued oversight and integral role in making it all happen. Over to you, Dr. Ali. Please share with us some of your thoughts around this operation and the broader picture.

Dr. Zawar Ali: Thank you, Stephen. Thank you for having me on this broadcast, and thank you for featuring our hospital here.

So I’m working as the medical adviser for this field hospital in Gaza. And I initially went up – went in on the 1st of January to help set up the hospital, to help set up the clinical team and the clinical operations inside the hospital. But the journey starts before that. In October, we realized that we needed to be – to provide direct services, health-care services, in Gaza. We have been in Gaza since 2008, but mostly work through partners.

But as we heard and we found out that tent infrastructure has been damaged, we understood that there is need for – to augment the health infrastructure through field hospitals. And we started planning for this. It was a difficult logistic operation, but we were able to get in our supplies and our infrastructure for the field hospital in Gaza by the end of December.

We also were recruiting people to manage the clinical operations of Gaza. We had a big international team, which was roughly around 40 international doctors and nurses and midwives, and we hired around 160 national staff. The first phase was setting up the hospital – setting up the tents, you know, the infrastructure for it, managing the clinical flow of the patients. We started off as an outpatient and an ER, which is called the EMP-1. And then, after starting those outpatient consultations plus ER, we moved to setting up the inpatient area of the hospital.

Our outpatient consultation started on the 4th of January, and by 16th of January we had started inpatient and surgical-plus section and reproductive-health services inside the hospital. These were augmented by nutrition, child protection, gender-based violence services, as well, in the hospital. And after that, this was followed by two phases of expansion, which we expanded the hospital from 50 beds to 140 beds. We were and still are facing difficulties with supplies, and one of my roles as a medical adviser is to focus on that here in Cairo.

The hospital – primary function of the hospital is to provide sexual and reproductive-health services to IDPs living in Rafah. As you know, a lot of people from the north have moved into Rafah. It’s a small border town that now hosts more than a million IDPs. So our primary focus was on sexual and reproductive-health services, as well as trauma care. Our field hospital is located at the border between Khan Younis and Rafah, and we see a lot of trauma coming into our hospital.

Just to cater to this trauma, we have two – (inaudible) – inside – set up inside the field hospital. We have – we’re also providing primary health care. We are providing physical rehabilitation, comprehensive emergency obstetric and newborn care, nutrition support, mental-health and child-protection services, and water and sanitation and hygiene services as well. We have an intensive-care unit, a fully stocked pharmacy, a radiology department which has x-ray and ultrasound services, and we run a fully functional lab as well as blood-transfusion services in the hospital.

Now, talking about the constraints and the rate of injuries that we are seeing, initially, when we set up the hospital, we had around 200 outpatient consultations per day. But because of the needs on ground, this has expanded to 600 patients in our outpatient-consultation areas every day. Our outpatient consultations are run through general practitioners, but also through specialists – for example, pediatricians, obstetrician and gynecologist, orthopedics, general surgery, and nutrition and mental-health consultations as well. We are providing 120 to 150 patients with emergency services through our ER daily. We are performing 20 major surgeries per day on average, and nine to 10 deliveries, which also includes C-sections.

Since opening up in January, our field hospital has provided critical medical assistance to almost 30,000 patients. We have performed more than 600 major surgeries and we have delivered more than 300 babies. Our major trauma log is blast or shatter injuries, but we also see gunshot wounds. The major surgeries that we perform are orthopedics in nature, which include external and internal fixations, damage-control surgeries, emergency laparotomies, skin grafts and flaps, as well as intubation.

We are also helping patients with medevac in case there is a need for intensive care or long-term care. We have a long history in disaster and conflict areas especially in resource limited settings and there are other challenges which are specific to this context as well and we try to address those challenges through innovation.

We’ve come up with some very innovative ways to manage the workload in the hospital. We have limitations in terms of communication equipment, in terms of supplies that do not reach the hospital. It’s difficult getting supplies into Rafah at the moment, as you show, and we deliver them to through different ways. For example – I’ll just quote an example – we don’t have comms equipment. We don’t have pagers. We don’t have, you know, communication equipment. It’s a huge field site. It’s more than 11,000 square meters.

So what we do with mass trauma is we have designated people who in case of emergency they start whistling and shout trauma, trauma, trauma, and in each department you have a designated person for that and that’s how we deal with trauma or mass casualties in these resource limited settings.

There are also challenges with insecurity as a field hospital with serving our patients in tents, which is not the best protection against shrapnel and gunfire. But we try to minimize that risk through our security measures through making sure that the most vulnerable parts of the hospital are secured. And we try to make sure that our patients as well as staff, they are provided some degree of safety.

I’ll speak a bit about the overall conditions of people living in Rafah. It’s a small border town which is south of Rafah that’s bordering the Egyptian – the Egypt border and prewar it had a population of 70 to a hundred thousand people. Now we have more than a million people in this area.

It’s very overcrowded. Because of the over crowdedness and so many people not having good wash and nutrition facilities it’s very easy for infectious disease to spread over there.

From a health perspective the needs are diverse. It’s not just the trauma but also the noncommunicable diseases that have not been addressed because of the lack of medications. We’re seeing those patients with complications.

There are also risks of infectious diseases. We don’t have a very good surveillance system inside Rafah but we still are reporting cases of measles, acute watery diarrhea, and jaundice, hepatitis cases inside Rafah. So those are the major immediate needs inside Rafah and but we’re trying our best to fulfill those needs through our health services inside Rafah.

Thank you. 

Dr. Morrison: Thank you, Dr. Ali. Very grateful that you’ve made the time and thank you for those prepared remarks. We’ll be back to you momentarily.

I want to turn now to Dr. Rik Peeperkorn from WHO for his thoughts. Rik, it’s great to have you back again. You’ve been very generous to us. Thank you so much.

Dr. Richard Peeperkorn: Thank you very much. Let me, again, first introduce myself. So Rik – my name is Rik Peeperkorn. I’m more than three years now the WHO representative for the occupied Palestinian territory and also, like, let me say something about what WHO is doing in our – yeah, we have three teams actually basically – a team in East Jerusalem, a team in Gaza, and a team in the West Bank.

And I think from the start, like, we’ve gone, of course, through a lot over the last three years and there’s been many escalations, et cetera, and so we know a little bit – we knew a little bit what and how.

But this – of course, this crisis unfortunately beats everything and with not only a regional impact but a global impact is, you know, what you can call a mega crisis and it changes also everything.

So normally I went to Gaza to work with my team there every month, almost there a week, and so all the hospitals which have been shown, et cetera, I know them very well. I mean, we work with them. We support them with a strong trauma-care program, supplies and equipment, health systems. We were even helping to establish an oncology, cancer hospital kind of thing, reproductive health, et cetera – the usual stuff WHO does, and much more.

So from when this crisis erupted, we were very quickly – I think, especially, I think, for WHO –we were super-operational. Like everyone, we lost our office and our warehouse in Gaza City, in the north. Most of our stuff who lived there had to move. We lost staff, our staff lost family members, friends, et cetera. And we opened straight away warehouses in the south, to be as operational as possible. So that was the first thing – medical supplies in. And we started already in October. Medical supplies in, trauma supplies in, essential medicines, et cetera.

And then – and to be sure, and I think against high risks, WHO, I think, was the first to really massively distribute medical supplies all over Gaza, including to hospitals in the north – the well-known, the Shifa, al-Ahli, Kamal Adwan, et cetera. And not only medical supplies, also fuel and sometimes food. Of course, in the overall scope, what was also described in the very good clip, too little and much more is needed. But that was one – our biggest focus, that’s one. Medical supplies and trauma supplies – essential medicine.

And the second part is, of course, EMTs. And I think that IMC is, of course one of – an outstanding emergency medical team. And we work very closely with IMC. We support IMC also with supplies and also with a nutritional rehabilitation unit. I’ll get back to that later. But there’s many other EMTs now. And how to coordinate them as good as possible, where can they be located, what is necessary, et cetera. The medevac is an – is an issue we focus on, of course, together with UNRWA, partners, other partners of the U.N., UNICEF, and other NGO and U.N. partners. Can we restore a little bit of primary health care? Outbreak prevention. I think my colleague mentioned something about it as well.

And, of course, malnutrition. I want to say something about that. And the last point is health information. I think it’s critically important especially that we bring out factual information, as good as possible. And because not only that we need factual information to make sure that our response is as targeted as possible, of course, also for efficacy reasons. Now I was in – during this mega-crisis I was in Gaza for three weeks, actually, from the – from early December, almost to Christmas, and then again in February – early February to late February. Next week I’m again going in with some colleagues again for three weeks, from the 3rd of April.

Just to always work with a team – our team of national and international staff. I want to maybe raise a few general, I think – and one thing I want to say, and I think probably everybody who works – has worked in Gaza, I’m sure that my colleague from IMC will say the same. I was for seven and a half years in Afghanistan before this job. I’ve been for 20 years – 25 years in central and southern Africa. I was part of the – in the ’90s – early ’90s, the whole HIV/AIDS epidemic. I saw the Rwandan refugees coming over Lake Kigali to northern Zambia, where we had to establish refugee camps, et cetera. And specifically, of course, in Afghanistan and the impact on HIV/AIDS in that, when there were ARVs, et cetera.

So I’ve seen some really grim scenes in my life. And where you say, hey, we could and should have done much more to prevent or to assist. But what I’ve seen in Gaza, witnessed, that I think I hear from so many humanitarian workers, is, in that sense, unparallelled. I mean, and it’s shocking also to realize that Gaza – definitely the health system was not perfect. But it was a relatively OK, functioning health system, which were producing indicators at par with its neighbors – actually, better than its neighbors. And to see where it now is quite, yeah, astounding.

And we see, of course, the 2.2 Palestinians, Gazans, who are in this epic humanitarian catastrophe at the moment, and facing inhumane conditions, widespread food insecurity. I think there’s a looming – though, in our view, and I think the U.N. – a partially avoidable famine. There’s a – we see the risk of starvation on the vulnerable, especially the under-five, et cetera, which has happened. Recent teams from WHO brought supplies to Kamal Adwan. And there’s also a task from WHO with PRCS to get patients from certain hospitals where they cannot get to care, especially in northern Gaza, to the south, or to medevac them outside. And we have brought quite a few patients now to IMC as well, as my colleague mentioned.

Health-care system is collapsing. At the moment, we talk only of 10 out of 36 hospitals. I want to say something, but let’s focus a bit on malnutrition. And, again, I want to say, there is no – you probably have seen the figures from the IPC report. It confirms what not only we ourselves, WHO, but many U.N. and other partners have been witnessing and reporting on a day-to-day basis over the last month. And it is quite surprising that, you know, it seems there’s too few people listen or help to act, so.

And before these hostilities and everything began, we talked about there was no malnutrition problem in Gaza. It was maybe you talked about .8 to .7 percent of children who were acutely malnourished. And there was definitely a problem with some micronutrient issues – iron deficiency in pregnant women, et cetera – but that was it. Now we talk in the northern governorates the figure of between 12.4 and 16.5 percent of the children are actually malnourished, acutely malnourished. And IPC warning for risk of a famine, you know, if this is not reversed by May in the north and by July – actually, in June/July in the south. So half the population, 1.1 (million), has experienced catastrophic food insecurity. It’s called IPC 5. And we’ve seen this enormously increase – greatly increase, even over the last couple of months. So in north Gaza, you talk about one in three children underage who, it’s true, is acutely malnourished – completely, I would say avoidable and, hopefully, also reversible.

Now, what are we doing together with partners? So Kamal Adwan, the hospital in the north, it’s the only pediatric hospital in the north, WHO’s supporting the establishment of a nutrition stabilization center to treat children there. The same case, et cetera, including in Al Aqsa. And currently, we are supporting Al Aqsa and Al Najjar, but also working with IMC, actually, to set up a stabilization center there. Many more are needed. And we need to expand them to actually all key hospitals in Gaza.

And that’ll be complex, because also Gazan health workers were never used to this kind of acute malnutrition. When I was in Afghanistan, 10 percent of the children were acutely malnourished. There was a nutrition rehabilitation unit in every referral hospital. Here, we are not used to that.

What is even more needed – and I think we need all partners for that – is to rapidly expand the so-called community management of acute malnutrition. With the Nutrition Cluster, plus the UNICEF as partners, we hope to push this forward. And the place should be flooded with these so-called ready-to-use therapeutic food this year, this RUTF. And we hope to reverse this completely avoidable trend.

My second – and maybe I have three points.

My second point is about the health system functionality. And you saw the film, and you heard the doctor speak and the health workers speak. So we talk about 10, 11 hospitals partly functioning. What I think that we are so concerned – we worried from this from the beginning – health services, hospitals, health facilities, health workers, they need to be protected. They need to protect that vital service. Whatever is happening, they need to be protected. And we’ve raised this constantly and from the start. And we had hopes that in the last months of this – of this conflict, of this crisis, there were more voices. And they said, yes, health, vital service need to be protected. And we witnessed, you know, lesser – health service being less effective.

Fortunately, over the last couple of weeks we’ve seen that Al-Shifa, which was – as we know, was hardly functional a couple of months ago – that through support, first of all, that incredible health workers, a lot of them volunteers, support WHO in parts, supplies, and equipment, et cetera. It was, again, a partly functional hospital. At least, it was again, actually, the last – just two weeks ago it was functioning again as the – as the trauma central of the north. Not third-level; I would say first-level hospital. But it was getting patients, it was expanding, et cetera – dialysis, et cetera.

Now, what we have seen over the last week, again, at the moment, the hospital is not functional. So it goes from functional, to barely functioning, not functional. And then we build it up again, we revive it, and now, again, non-functional. Shifa is absolutely needed in the north. Actually, it’s needed for all of – all of Gaza. WHO tried to assist. We were even invited to assist, well, Thursday and today. Unfortunately, our missions were refused. And we were going to bring fuel and also, of course, do an assessment.

The same, Nasser Medical Complex. I discussed it last time. It was also in the same. The second time I was in Gaza, we visited that hospital twice. We were not allowed in to do an assessment. Then my team was, finally. We did a lot of patients – we call it transfer medevac to hospitals in the south and Al Aqsa, including IMC by the way. And currently, that hospital is non-functional. This was what I would say the Shifa of the south. It had all the specializations. It’s absolutely needed. I mean, like, field hospitals, like IMC, are incredibly important; but my colleague will confirm you cannot run health services with a number of field hospitals. You need to build on the existing health infrastructure in the health system, which is still there.

Last hospital, Al-Amal, the PRCS hospital. You saw it in the news, et cetera, again.

So we are deeply concerned about that, including we see a huge number of health workers being detained, sometimes completely for their families, their organization is unclear about their whereabouts. And this is what my team tell me. And I will – I heard it even last time, is a lot of health workers – specifically in the north, but all over – they’re scared. They’re scared to operate. They’re scared to operate because they see, well, see what happened in Shifa? See what happens in Nasser? See what happened in Al-Amal? See what happens in this hospital? And they are scared, of course, to be – if there will be siege, that they will be arrested and detained, et cetera.

And we already saw – I mean, Gaza used to have 25,000 health workers – 20 - 25,000; 11,000 nurses/midwives; 5 to 6,000 medical doctors; 5 to 600 medical specialists. Gazans can do a lot themselves. We estimate that at the moment maybe 20 to 30 percent of them is operational. There’s a lot of volunteers. And we want to make sure that they can do their work with all our – all our partners.

Now, the medevac, we discussed that a few times. I still think we consistently need to raise, then, this program. We have estimated that 8,000-plus cases needs referral. Twenty-six percent, or even more, are what I would say are regular patients. Twenty-six percent, for example, are cancer cases. Forty-three percent, estimated, war and war-related injuries – all the horrible trauma, the spinal injuries, the amputees, a lot of the – a lot of the reconstructive surgery which is needed, which cannot take place now in Gaza. Kidney dialysis, et cetera.

And currently there’s an ad hoc system operational. We only have seen since the start of this crisis 2,630 patients referred. That’s way too little. Egypt says they are ready. Other countries reached out to assist and said we have to make this work. WHO a number of times did a proposal how to do this an organized and a transparent way, and we have to push that medical evacuation. It will – first of all, it’s a right for the patient to get a treatment they are able to get. But, secondly, will also help to relieve a completely overloaded and under-capacitated health system on its – on its knees.

Let me stop there as an introduction. Thank you very much, Steve.

Dr. Morrison: Thank you. Thank you.

Before we turn to my colleague Michelle Strucke, who’s the director of the Humanitarian Agenda, I just want to invite Dr. Ali to respond to anything that’s come forward in Dr. Peeperkorn’s remarks. Ali?

Dr. Ali: I echo Dr. Peeperkorn’s thoughts on what he mentioned. Yes, there is a need, especially in terms of field hospitals. Those are good solutions to augment the health system, but it’s only a temporary solution. There is a lot of work that needs to be done in rebuilding the existing hospital capacity.

Of course, health-care infrastructure and health-care workers, they should not be targeted. It’s an exemption service. You have to maintain security for health-care infrastructure and health-care workers. Health-care workers in danger, in violent situations, or a threat of violence to them will be very difficult to know the consequence of – consequences of that on the health system would be immense and are immense in Gaza.

I also echo his thoughts on malnutrition. There is a malnutrition crisis going on in Gaza at the moment, and it can be at catastrophic levels, especially in the north. It’s creeping down south as well.

But his answer on the humanitarian space, that has to increase. It’s very narrow in terms of supplies, in terms of security. It’s difficult for us to go into the community and do community interventions that are much needed because of the insecurity. These are things that we need to address to make sure that we can save lives inside Gaza.

Dr. Morrison: Thank you.

I want to invite my colleague and friend, dear friend here, Michelle Strucke, to offer some thoughts.

Michelle Strucke: Thank you so much. And thank you, Dr. Ali and Dr. Peeperkorn, for these remarks.

Watching this video today really brought me back to the work that I did with the Syrian-American Medical Society, working with organizations like IMC in field hospitals in Syria. I did that remotely from D.C. But just watching that, I thought that there were some themes to draw out that our colleagues here have raised today.

In the video, you can see this level of destruction. You can see how many ambulances were damaged and affected. Each of those would have been helping, you know, countless patients be able to get treatment. We’ve seen – the WHO has said that 104 ambulances have already been affected by health attacks. Fifty-four sustained damage in Gaza. And this is a very dangerous operation.

So the colleagues that are, you know, providing health care in this environment, local and international, are under great risk, as more than 160 aid workers have been killed in the conflict and 118 health workers have been detained and arrested. So I was definitely contemplating how difficult that situation is.

At the same time, in the video, while we see the physical destruction, just hearing, you know, about the incredible capabilities that have been stood up, I wanted to repeat the point that these kinds of field hospitals have, you know, lots of limitations. They’re not referral facilities. They’re not hospitals that can handle the gross amount of needs that we see in Gaza. So that – the fact that the existing health infrastructure is so devastated continues to be a tragedy.

One of the things that I was thinking about as well is that aid workers, health workers, they’re not superhuman. We heard from colleagues how aid workers and the health workers are themselves facing the same things that others are facing – lack of electricity for 165 days, lack of health themselves, health care for themselves and their families. They’re facing themselves food insecurity. So to have to be put in a position, as a health worker, to provide care to people when you and your own family are not taken care of is extremely stressful. So I wanted to share those things.

In addition, one of the biggest tragedies, I think, of humanitarians is that when you’re watching a manmade crisis happen, it’s as if you can see preventable deaths in slow motion. I’ve heard the kind of looming famine described as a massacre in slow motion, this idea that you can look at all the numbers that our colleagues are citing – incredible, you know, data that they’re gathering despite great conditions – and can see that many more lives are going to be lost.

And all of this, knowing that it’s preventable, that if more border crossings were open, if hospitals and medical workers were able to get the supplies that they should be able to get, if trucks were not being stopped and having to be sent back because they can’t make the amount of time that they’re given to get supplies in, if warehouses were able to be accessed. These are the kinds of human tragedies that we’re watching happen and are, sadly, predictable and that I think is one of the difficulties of humanitarian assistance, that in a situation where there are real tangible logistical things that could happen, choices – policy choices that could be made to allow more aid inside and not to obstruct it that itself leads to these kinds of crises.

So to share that, you know, these – this preventable nature I think is quite tragic. As we’re watching the specter of a potential Rafah invasion, a ground incursion, you know, I want to mention to those who are following this conflict know that bombardment is still happening. The active hostilities are still happening and including in areas that people are – you know, like Rafah where people are sheltering in great numbers.

So as there’s a specter of this potential ground invasion the question of how to ensure that civilians are out of harm’s way, to ensure that health care facilities are protected so that they’re not subject to attacks, all of these are, I think, the most important questions that D.C. policymakers I know this week are thinking about as they receive Israeli counterparts that are coming to speak to them.

The last point that I’ll mention is just that the – again, when we watch the video another, I think, important thing to raise is just how difficult the situation is when doctors are working to provide care without adequate medical treatments to be able to ease the suffering of patients.

The video didn’t show that, you know, quite of – the kind of sounds that I’m sure people are hearing as it was edited but it’s a(n) extremely difficult kind of human situation as a person of conscience to watch this unfold and know that people are suffering the way they are.

Dr. Morrison: Thank you, Michelle.

Let’s come back to Rik and then to Zawar for your thoughts on what we’ve just heard here. Over to you, Rik.

Dr. Peeperkorn: Well, I want to respond once to my colleague Ali from the IMC and then to Michelle, I think.

Mr. Morrison: Yeah.

Dr. Peeperkorn: So I visited also IMC and I saw for myself actually – actually very fortunate that that happened. So on the moment we visited, there were two severe trauma patients came in, were rushed inside. They said one had to be referred to the European Gaza Hospital and the other one was stabilized, et cetera. But, like, I witnessed how professional they worked and, yeah, I think it’s – definitely and for me it was – and maybe you guys might have worked at many of them, but one of the more model field hospital and professional – well-structured, well-laid-out, et cetera.

Well, so we were really – I mean, they use a lot of supplies we, as WHO provided. And so for me it’s – definitely there’s needs for a few more of these hospitals on strategic locations. But I think what I tried to raise and I think with Ali confirmed, it cannot replace the existing health system. We need to make sure that the existing health system is protected, that it is strengthened, that it goes back – it’s on its knees; it goes back on its feet, et cetera. And that we link EMTs to some of those existing referral hospitals and then hopefully expand that capacity, et cetera, that’s what we should do.

And I think what – Michelle made a couple of points on the – well, I think first you made this point on the – on the incursion and if this would happen. So the last time I was in Gaza, we had discussions on this with a couple of hospitals in Rafah, including IMC. And if there would be an incursion in Rafah, most likely IMC will – and maybe Ali wants to say something about it – they would probably have to shift, as well, to a backup place somewhere else.

But it also – what is I think extremely worrisome, there is a hospital, Al Najjar Hospital, which was – because Rafah was – I know Rafah as a sleepy little town of less than 200,000 people, and now there’s 1.5 million. And Al Najjar Hospital a relatively small hospital. It was – I think it was actually more recently expanded primary health-care clinic, level four, and now it is – it is functioning as a kind of referral hospital. But already then the director and chief are making plans in case there would be an incursion, because it would be likely they will be also on that line and they will go from partly functional, fully functional, very quickly to barely functional. And what to do and where to go? So they were making plans already where – you know, and could they shift something to Al Aqsa in the middle area and this and that, plans like that – plans which you do not want to make and which you should not want to make.

The other pragmatic thing is at the moment Al-Najjar, including IMC, they refer, and certain medical patients are referred to European Gaza Hospital, because there they have the diagnostic capacity. Now, that line would be also blocked if there would be an incursion. So all those paper plans are made how to – how to – what could – what could we then still do and how would we do that. You don’t want to make these plans, and those plans should also not be necessary. And I want to raise that very quickly.

And the point of – of course, if we would see more shifts and internal migration of already-displaced people, so where would they go? They will have to go to the – to the coast, to the middle area, which is also completely overcrowded. And I think it was, I believe, Ali who mentioned on the – on the – what we already see now, the diseases, and we’ve raised a couple of times acute respiratory infections, et cetera, are more than half a million instances are diarrhea, 20 times as much as normal and almost 300,000 cases; jaundice, 15,000. So it’s all – it all reflects the overcrowding, and the lack of water and sanitation, and everything around that. And that would, of course, only be amplified if you get more and more people on the – on the move.

So there is, of course this constant, constant cry out for a – for a sustained ceasefire, and that we can start thinking about earlier recovery, again. And I agree with Ali. Everywhere, when I travel to the north just – but also in Khan Younis, and even in Rafah – but especially Khan Younis and the north – the destruction is immense. I’ve never witnessed something like that in my life. So there will be – there will be a need to such a large scale early recovery, rehabilitation, and reconstruction effort. And of course, at WHO, we will definitely focus on everything related to health, but as we know, so much more is needed. I hope member states has realized that and started thinking along those lines.

And the last point I want to make – Michelle made this – what is needed, I mean, like, and how do we flood the place with food and specific foods; and also, by the way, how do we restore some of the food production. Gaza has a lot of fishery. Gaza has a lot of poultry, eggs, and a lot of vegetable and fruits. That is all – all of it is destroyed or that’s not functional, again. That should be made functional again.

I mean, that’s just our – and on the – a lot of – we hear and we see a lot of the news about alternatives for entry in Gaza: maritime corridor, the so-called pier – the pier, the airdrops, et cetera. Well, we are open for everything. I mean, we – the more, the better. But there is no alternative for land routes. The land routes – and if the land routes would properly function from – through Rafah, through Jordan, but also the use of, for example, the Ashkelon port, which is 20 kilometers from Gaza, which was always used for Gaza; another entry north – in the north of Gaza; clearance of this – of these roads. And we can see it can happen very quickly. There’s a whole new road constructed from east to west. So clearance of these roads, et cetera, so that you can have 15 humanitarian convoys per day to the north and that you have constant humanitarian convoys in the – in the south. A lot of this can be addressed. So this is where – there’s no alternative for proper land routes. I just want to make that point right now.

Over to you, Steve.

Dr. Morrison: Thank you. Thank you, Rik.

Zawar, maybe you could say a few words about the contingency planning. I mean, here in Washington, this week we have visiting senior-level high-ranking delegations from the Israeli government. There’s an active debate around will there be a siege or not, what would the – what conditions should be insisted upon in terms of respect of civilian safety and well-being in this context, how do we make judgments around that. We had our funding bill passed, which carries the government through October, which includes a provision banning any additional U.S. funding for the next 12 months to UNRWA, which was a setback for many of us who have argued that UNRWA remains absolutely essential here.

Tell me, Zawar, how are – how is the team, the IMC team, dealing with these possible contingencies as you – as you think about this field hospital and what may lie ahead?

Dr. Ali: We constantly analyze the different factors that come into this analysis, metrics. And we’re constantly thinking about different ways to ensure that, in case of an invasion of Rafah, in case of any other eventuality, we’re able to serve our patients.

As Rik mentioned, there is a budding health system in Rafah. They assist more than a million people. And the health system includes the health-care providers, as well as the patients. We’ve gotten used to a certain health system. There is some – with a lot of effort from WHO, from other actors within Gaza, there is somewhat coordination between these different actors. Patients know where to go, how to access health. To a certain degree, they can access health as well. But if an invasion happens in there, of course we can come up with contingency plans, but it doesn’t really – it wouldn’t ever, you know, replace the existing health system inside Rafah.

If an invasion happens, we’re looking at it from and we’ve discussed this from a health-care provider perspective, but from the patients’ perspective I can tell you that patients who used to go to, for example, to the EGA – to the European Gaza Hospital – once there were hostilities near the hospital they had some hesitancy in going to that hospital, and a lot of those patients started coming to us. It was the same case with ambulance drivers as well. So once there are hostilities in an area or health-care infrastructure is damaged during an invasion of Rafah, from the patients’ perspective it would be very difficult to go back to those hospitals. I would say that there was a preference from the patient side to come to us, as well, because we were relatively unharmed during this phase of war. So we have to look at it from that perspective. A patient-centered approach to health system is also important.

And these interlinkages between different actors in Rafah who are providing health services and actors who are coordinating these services, if this stops, we have contingency plans. We can go to – we might have to shift our hospitals in those cases. But it would be very difficult to replace the trust that the people have in these health services.

That is where I’ll stop on that. Thanks.

Dr. Morrison: Are you both operating on the assumption that in the next four to eight weeks we will see a rapidly escalating problem of famine and starvation regardless of what scenario we see? That this is – I mean, when I read the IPC report that just came out, it was pretty stark and it was exceptionally detailed in the modeling, in the data that was used. I just wanted to ask both of you, I mean, you’re consumers and contributors to this work. You’re monitoring the conditions of the populations served, but you have to be thinking ahead about what the next phase is going to look like. How does this specter of famine and starvation figure in your thinking? Rik?

Dr. Peeperkorn: Sorry. Yeah, I find this a difficult one. Like, so when I read the reports – and we contributed to these. Some of my colleague(s) contributed to it and – with data, et cetera. And of course we analyze. Of course, we discuss this in a wider group. And as WHO, where we work very much on the – at the hospital/health facility level and support, and of course in the community level with – so with the health cluster and with the nutrition cluster. Folks, then you’re already too late. You’re already on the receiving end. I mean, like, you’re establishing therapeutic feeding center or stabilization centers and saying, oh, we should do that, and as quickly as possible, and more. But, indeed, you want to – you want to prevent actually that they are really going to be used or used on a massive scale.

I still have some – and although my hopes have been thwarted in the past as well, I still have some hope that the world has waken [sic; woken] up. The pressure should be that the place specifically in the north but also in the south should be flooded – flooded not only with food – because a lot of the food, of course, has low nutritional value. But this food – diversified foods, including what is these community malnutrition centers with RUTF, et cetera. And more diverse – and that’s – the only thing what – at the moment how that can happen if the land routes are optimal use. And that’s not only to Gaza, but specifically within Gaza. That this is happening much more.

And not – and I’ll say, in early March I had a bit of hope that even from WHO some of our missions were going into the north. In January and February we really struggled. We had a lot of mission denied, delayed, canceled for whatever reasons. And we pushed and pulled and this and that. And then WHO is a relatively small – though we should talk about bulk supplies. You talk about convoys. You talk about much more. And for me, I think this is possible. So I still have some vague hope that the land routes will be optimal use, that there will be a more workable deconfliction mechanism for where you organize those missions, and that’s the north but also the south.

You need to do that. And, of course, with a carefully planned way. And some of the U.N. agencies are doing very well on that. If it is UNRWA, or WFP, et cetera. They know how to do that. You need to discuss with your community leaders. You need to use your influencers, et cetera, to make sure. We’ve seen a lot of breakdown of law and order over the last months. Is that surprising? No, not at all. I mean, not at all. People are desperate. There’s a lot of things going on.

So you have to take that away. Organize that better. Make sure that these land routes are fully operational. And I still have a vague hope that this trend can be reversed so that, yeah, that we could – however, we should be prepared. And this is where I’m now pushing my team – and we’re a midsized team, so we do this with all partners including all EMTs, like, of course, IMC, et cetera. That we, indeed, establish a stabilization, or a nutritional rehabilitation unit, whatever you call it, in all key hospitals. Make sure supplies are there. Make sure staff are trained and know how to operate that. More importantly is community centers, and flood the place. I still think that we – and hope – I hope and expect that we can reverse these trends.

Dr. Morrison: Thank you. I think that – Rik, I think that these very concrete priorities are quite important now to convey to a Washington audience in particular where there is this active debate going on this week and to hear those messages about what needs to happen in what level of prioritization in order to avoid the worst possible outcomes.

Zawar, did you want to add anything to what Rik said? And then we’re going to come to Michelle for the closing segment of our program.

Dr. Ali: So I would say I’m not as hopeful as Rik is when it comes to the nutrition intervention, because the main part of that is going into the community. Currently in Gaza I don’t see the conditions where it is easy for aid workers to go into the community and safely carry out these nutrition activities. There is, of course, a border, like at Rafah, the land routes that Rik is talking about. But then once you cross Rafah, then this is over 2 million people. And reaching all of them in these conditions, it’s very difficult. We have to prepare for a scenario where there is a proper malnutrition crisis, and that is what we’re coordinating with, as Rik said, setting up stabilization centers. But that is a reactive step. We need to be able to into the community and avert this disaster. Thanks.

Dr. Morrison: Thank you. Michelle.

Ms. Strucke: I believe what we’re hearing – which I think is really important, as you said, for the Washington audience – is that a lot of these constraints that would cause our humanitarian colleagues to be able to save lives are access constraints. They’re things that policymakers can make decisions to get around. And it’s, I think, extremely important to emphasize that the, you know, heroic actions and ingenious actions of coming up with stopgap measures – like the air drops and like the maritime corridor – are important. But they, again, are no replacement for land routes. They’re no replacement for supplies getting in and for access within Gaza to be – to be facilitated so that people are able to bring the badly needed aid to people in need right now.

I think it’s really important as well to emphasize that this is not someone else’s responsibility. The Israeli government has a responsibility to facilitate and provide that humanitarian aid. As much as international organizations, nonprofit organizations play a critical role, they are not a replacement, as we mentioned, for Gaza’s actual infrastructure, for them to be able to be self-reliant, and then for authorities and parties that are engaged in this conflict to allow humanitarian aid in. And on that too, it’s obviously extremely important that Hamas stops using these illegal tactics of putting people – embedding in the population and, as well, playing a huge role in causing these difficulties.

That being said, in many conflicts around the world we have parties of the conflict that don’t play by the rules. That doesn’t take away any obligation to provide that humanitarian aid and make sure that it gets in. So again, access continues to be such an important issue. And choices that are made, like continuing to have electricity cut off, continue to hinder access as well because aid workers are not able to effectively communicate with one another. I was really shocked by hearing that, you know, having a person that had to just shout trauma because the hospitals are not able to have communications inside. That’s something that should stay with all of us. It’s something that should not be happening in any humanitarian situation, particularly now for almost six months.

So I do hope that policymakers again consider these larger, sustainable actions that can try to prevent that manmade tragedy that we’re seeing unfold, because while we can’t undo the many lives that have been lost, and limbs that have been lost, and family members, there are still people that could be saved.

Dr. Morrison: Thank you, Michelle. We’re getting towards the end of our hour here. I want to come back to Dr. Zawar Ali and Dr. Rik Peeperkorn for their closing thoughts. I guess the question I would pose to you: We’ve heard a lot of very specific and concrete suggestions around those things that absolutely need to happen in order to change this picture and change this dynamic. So we’ve got a lot of that already. This has been a very rich – a very rich and very valuable conversation. Is there some top line message that you wish to convey in closing here? This is a big week of debate and discussion here in Washington about what happens next. And this is an opportunity really to convey of what each of you feel is most important in communicating to policymakers who may or may not fully grasp what’s going on, on the ground.

So I’m going to start with you, Dr. Ali. What would be your – what would be your mainline message to close with?

Dr. Ali: We need to ensure that supplies go into Gaza to – so for us to be – or, for all health actors to be able to provide services inside Gaza. Two, healthcare service delivery points, healthcare infrastructure in general, needs to be protected. And, three, we should have the ability to increase these health service delivery points, because the needs are massive. So, supplies, protection of healthcare infrastructure, and the ability to expand healthcare in Gaza at the moment.

Dr. Morrison: Thank you. Thank you, Zawar.


Dr. Peeperkorn: I have not so much more to add. I think Ali’s very clear. I think also Michelle was very clear in her – in her closing statement.

We discussed the whole issue. And, unfortunately, it comes back to access – proper access all the time and proper access to, but specifically within, Gaza; and using, indeed, these land routes in a much more effective and efficient way – in a way that is safe for humanitarian convoys to move and to do their things, which they should do, and move not just one or two a day – no, tens a day; I mean, like we flood the place.

I also think what I heard – because if you can get proper access and it becomes more safe, even if there’s an ongoing war, there should be humanitarian corridors; you should be able to move and do your work in a relatively safe environment. That’s the only way that you can create and get back to links with the communities. At the moment, when we do missions at the hospitals, we know the hospital, the hospital director; we know the hospital staff, medical specialists, et cetera, although of course they change, et cetera; we know that.

But that’s the only ones you talk to. I think – Ali, I think, made one good point. You need to gain the trust of the community. At the moment, the Gazans don’t trust anyone. They lost faith in, I would say – and I’m talking about the Gazan population, people on the ground. They lost faith in a lot of what’s happening in the world and how they are supported. And I think when you make the work of humanitarian partners, when you do not facilitate but you make more difficult, et cetera, you create even more issues and more unnecessary problems.

Last point. I think you said on that – I think, yes, we should also want metrics with regard to malnutrition, incursion, and this and that. In a way, we have to prepare for the worst. And we should prepare for that, our humanitarian partners, as good as possible. And that is complex because Ali can – will tell you as well: There is, in my view, very few humanitarian partners actually operational in Gaza. It’s very difficult to be operational in Gaza. We didn’t even discuss that. Your own national team – to get your own national team operational, and – who have been traumatized and that have been shifted, the same like any other Gazans, six, seven times, who lost family members. We lost our colleague. Everyone has a story. Everyone has a story. And to get them back – and it’s amazing that so many are still operational and focused.

But to get – to rebuild that trust, you – finally, the Gazans will have to recreate, you know, their society and their world. Palestinians need to do that. And there’s a lot of capacity there. So we need to somehow rebuild that trust and be able to reach out to community leaders and do our thing. So prepare for the worst, but I hope the worst is – the worst, in my view, is absolutely not needed. A food and a malnutrition crisis, et cetera, is looming, and famine is looming, but it is – it can be prevented. Trends can be reversed. But we have to, unfortunately, prepare for the worst.

Let me close there.

Dr. Morrison: Thank you.

Dr. Zawar Ali, Dr. Rik Peeperkorn, we’re very grateful to each of you for your courage and your commitment and your leadership in this extraordinarily difficult situation, and to the organizations that you work for, IMC, International Medical Corps, and World Health Organization. I want to also thank my colleague Michelle Strucke for joining with us here in putting this broadcast series together.

As we’ve discussed, this is a big week for debate over what comes next, and these opinions, these thoughts, these insights are going to be very, very important in trying to shape those outcomes. Thank you to all of our audience who’ve joined us for this hour. We’re adjourned. Thank you.