Introduction:
The Gaza Strip is a stretch of land along the Mediterranean shoreline that has been the focus of a longstanding and deeply ingrained dispute between Israel and Palestine. The recent surge in hostilities between Israel and Gaza during 2023 and 2024 has resulted in damage primarily impacting the health care system. As bombs continue to rain down on the region, civilians are suffering injuries from airstrikes, bombardments and ground combat operations. In regions of conflict where explosive weaponry prevails, one can often find individuals suffering from potentially fatal injuries such as traumatic brain injuries (TBIs) and spinal cord injury that necessitate neurosurgeons’ expertise.
For this issue of AANS Neurosurgeon that focuses on global neurosurgery, we delve into the obstacles that neurosurgeons encounter in Gaza amidst the continuing conflict. These difficulties range from a lack of staff to the devastation of health care facilities and interruptions in obtaining crucial surgical equipment as well as the moral quandaries that surface when tending to those injured in war situations. The circumstances in Gaza bring attention to the challenges confronted by health care workers in conflict zones while underscoring the pressing requirements of neurosurgical treatment in a besieged region.
Before the War Health Care Faced Challenges
The health care system in Gaza has been facing challenges prior to the conflict outbreak. The area has been under restriction by Israel since 2007 limiting access to supplies and medical equipment. This blockade has severely impacted the health care infrastructure in Gaza leading to assistance from international sources. Medical essentials such as antibiotics and surgical tools are frequently low in supply. In addition, the ability to fix or replace damaged equipment is greatly limited.
Before the conflict erupted in Gaza, there were a handful of functioning hospitals. The public health care system in Gaza which treats the majority of the population faced challenges such as inadequate financial support and outdated medical equipment. Organizations such as the World Health Organization (WHO), Médecins Sans Frontières (MSF) and the Red Crescent Society provided assistance to ensuring health care services were sustained. Despite receiving assistance, hospitals are challenged by frequent power shortages due to Gaza’s energy crisis. This is especially problematic in neurosurgery where constant power supply and precise environmental conditions are non-negotiable.
Health care was already facing challenges due to the departure of trained physicians and nurses seeking better prospects or avoidance of the hardships of living in a conflict-ridden region. This exodus resulted in workforce shortages in various specialties including neurosurgery. Prior to the conflict, the number of neurosurgeons was greatly exceeded by the population that it treated as only a handful of neurosurgeons were in Gaza to treat the population in excess of two million people. As such, it was not uncommon for those in need of neurosurgical care to seek it elsewhere including the West Bank, Egypt or Israel.
Challenges During the War:
Hospital Bombings
The destruction of health care facilities, particularly hospitals and clinics with specialized units like neurosurgery, has been one of the most devastating consequences of the ongoing conflict in Gaza. Over the course of the war, numerous hospitals have been hit by airstrikes, artillery or collateral damage from nearby bombings. These attacks have not only caused significant loss of life but have also crippled Gaza’s already fragile health care infrastructure.
Hospitals like Al-Shifa, Al-Aqsa, Al-Quds, Nasser and others which were critical hubs for trauma care, have been repeatedly damaged. Al-Shifa Hospital, the largest and most well-equipped medical facility in Gaza, has frequently been at the center of war operations, treating thousands of casualties while under threat. Despite its critical role, parts of the hospital have been damaged by bombings, severely disrupting its operations. The neurosurgical unit, which requires specific tools, advanced imaging equipment and sterile conditions, has been particularly hard-hit by these interruptions. When the physical infrastructure of a hospital is damaged, entire departments, including operating rooms and intensive care units (ICUs), can be rendered non-functional, leaving patients without access to life-saving care.
In the aftermath of these bombings, hospitals are left to operate in severely compromised conditions. Makeshift operating rooms are set up in hospital basements, corridors or other available spaces, often without the necessary equipment or sanitary conditions required for complex surgeries like those in neurosurgery. These temporary solutions, while essential for emergency care, are far from ideal for the delicate and precise nature of neurosurgical operations. Without functioning equipment, sterile environments and adequate post-operative care, the risks to patients are amplified, leading to higher mortality and complication rates.
The destruction of hospitals also forces the evacuation of patients in critical condition, including those undergoing surgery. When hospitals are bombed, doctors are often faced with the impossible decision of continuing life-saving surgeries in unsafe conditions or evacuating patients who may not survive transport. In some instances, operations are interrupted mid-procedure due to imminent danger, leading to tragic outcomes for patients who could not receive the care they needed in time.
The Impact of Losing Surgical Rooms and Critical Care Units
The absence of working operating rooms and ICUs greatly hinders the quality of neurosurgical care delivered.
The closure of care units (ICUs) poses a challenge for patients undergoing neurosurgeries as they usually need extensive monitoring during the recovery period after the operation. Individuals recovering from brain and spinal procedures are vulnerable to complications such as brain swelling, bleeding in the brain and lungs and difficulty breathing which all demand care. In the absence of equipped ICUs, it becomes incredibly difficult to deliver the required level of attention to stabilize these patients and avert any issues post-surgery. The limited availability of ICU beds has resulted in increased death rates among patients undergoing neurosurgery due to the challenges faced by physicians in delivering post-surgical treatment in an under resourced setting.
Often times, hospitals without functioning operating rooms and intensive care units are compelled to redirect patients to health care centers. Ambulances frequently face challenges navigating through zones of conflict safely while certain hospitals that remain operational find themselves inundated with patients. The fragmentation of this system, for referring patients to specialists puts more pressure on neurosurgeons and lowers the likelihood of successful results for individuals.
The Difficulties in Sustaining Operational Neurological Surgery Departments
Operating a neurosurgical department in Gaza has always been challenging given the continuous blockade and persistent scarcity of resources even prewar times. This task has become exceedingly difficult during the conflict. Neurosurgical departments depend on delicate equipment such as imaging devices, surgical microscopes and neuro navigation systems, for accurate diagnosis and treatment of brain and spinal injuries. These devices can be rendered inoperable due to power failures, attacks or negligence in upkeep.
A major issue that neurosurgeons in Gaza encounter are power disruptions during surgery. Electrical interruptions in Gaza require backup generators; unfortunately, fuel scarcities often lead to generator failure and interruption of surgical care.
The lack of equipment and supplies results in using outdated tools as alternatives. Neurosurgeons have to depend upon physical examinations or less advanced imaging methods; this can sometimes result in diagnoses or delays in treatment.
Neurosurgeons frequently encounter situations where vital items such as sterilized instruments, sutures and medications are unavailable. The scarcity of these supplies puts pressure on surgeons to come up with solutions.
Challenges in Sterile Environments and Infection Control
Maintaining sterile environments is critical to prevent infections; failure to do so can have fatal consequences, especially in patients with head or spinal injuries. In a well-functioning health care system, sterilization protocols minimize the risk of contamination. However, in Gaza’s war-torn hospitals, these basic standards of care are difficult to maintain.
The constant bombardment and destruction of infrastructure have compromised water supplies and sanitation systems in many hospitals. Clean water is essential for sterilizing surgical instruments, maintaining clean operating rooms and ensuring that health care workers can follow proper hygiene practices. In many hospitals, the lack of access to clean water has led to the use of improvised and less-than-ideal methods for cleaning instruments and maintaining sterile fields.
Infection control is further undermined by the overcrowded conditions in hospitals. The influx of patients during mass casualty events overwhelms the capacity of medical facilities, forcing hospitals to admit more patients than they can reasonably care for. As a result, operating rooms and post-surgical recovery areas are often packed with patients, making it difficult to maintain the level of cleanliness and control needed to prevent infections.
Blockade and Restricted Medical Supplies
In the context of war, the shortage of medical supplies becomes even more acute; medications, equipment and replacement parts can be difficult to procure in war zones.
Delays in Receiving Critical Supplies
The delays in receiving medical supplies, even when they are approved for entry, present another major obstacle to effective neurosurgical care. The bureaucratic process for importing medical supplies into Gaza can be slow and complicated, often requiring approvals from multiple authorities. In many cases, medical supplies languish at border crossings for days or weeks, significantly delaying their arrival at hospitals.
During these delays, patients suffer.
Navigating Challenges in a War Setting with Limited Resources
Due to war induced challenges, neurosurgeons are forced to think outside the box and take risks in order to provide medical care. Some surgeons are adapting equipment originally meant for different procedures. For instance, sometimes, handheld surgical instruments are substituted for more effective and safer power tools that are either unavailable or damaged. Though these innovative solutions showcase the resourcefulness and determination of Gaza’s health care providers, they also expose patients to notable hazards.
In spite of the obstacles, health care workers in Gaza persist in delivering care to the best of their capabilities. Yet the harm inflicted upon hospitals and tools has greatly undermined the standard and accessibility of care. The inability to sustain neurosurgical wards in a conflict area where head and spinal injuries are occurring serves as a poignant reflection of the toll of war on humanity.
Effects of Delayed Treatment
Treatment delays often occur as an inevitable result of the conflict in Gaza region. Those who suffer from brain injuries or spinal cord issues face risks when neurosurgeries are postponed.
Many patients must endure delays in receiving care due to the lack of neurosurgeons and resources for operations. This often results in extended periods before surgery can be performed.
The moral dilemma is brought to light when considering how long doctors can ethically postpone treatment for a patient in order to attend to another individual’s needs in the context of interventions where every moment counts. This delicate balance, between the need for care and the limited availability of resources, is intertwined with considerations that add layers of complexity.
Challenges Faced During Recovery After Surgery
Recovery, for neurosurgical patients, is greatly influenced by rehabilitation efforts. In Gaza, the challenge of offering holistic rehabilitation services becomes nearly insurmountable. Patients often require therapy and support, over months or even years to regain functionality and adjust to life after disability.
Unfortunately, due to the destruction of facilities and the shortage of rehabilitation professionals, a significant number of patients in Gaza are unable to obtain necessary care.
In Summary:
The Gaza situation requires a unified global effort to not only provide assistance but to also revive the health care infrastructure. There is a need for cooperation, among bodies, governments and nonprofit organizations to offer financial support, specialized knowledge and training to enhance Gaza’s health care capabilities. Equally as important is addressing the underlying conflict; without peace and stability, rebuilding efforts will be unsuccessful.
