'A quarter were children': One surgeon's traumatic memories of operating on the victims of Gaza's war

With the broken bodies queuing up at the resource-starved Nasser Hospital, Saladin Sawan had to choose who might survive and who could not be saved...

Dr Saladin Sawan, right, has given The National his account of being a surgeon in Gaza. Photo: Saladin Sawan

On his first day back in Gaza, Saladin Sawan was quickly made aware of how bad things had become. Unlike his first surgical rotation a year ago, where there was “only” one major casualty event a week, there were two or three a day when he returned.

It was not just the casualties but the nature of the wounds the surgeon was seeing. He was forced to operate under the harshest conditions experienced during the Syrian-born doctor's long career. Instead of blast and fragmentation injuries, most were to an area of the body that surgeons dread – the pelvis.

It has been reported that of the 1,760 Palestinians killed since June seeking food, 994 died near the notorious Gaza Humanitarian Fund (GHF) sites, although the aid distributors claimed they had fired only “warning shots”.

A child is injured in an Israeli air strike on Rafah, Gaza. AFP

If that gunfire was indeed intended to be fired at people’s feet, many rounds certainly reached the midriff, causing scores of injuries.

“Pelvic injuries are notorious,” the British-trained doctor told The National. “You can injure several organs at once. They are devastating for the patient and they consume enormous hospital time.”

Young and old bore devastating entry points from rifle fire. “These weren’t fragmentation injuries,” he said. “These children were just standing around and they were directly shot.”

Saladin Sawan, a surgeon who operated in Gaza. Photo: Saladin Sawan

On its knees

Dr Sawan first operated in Gaza for five weeks in December last year but returned to a medical system pushed beyond breaking point, where every hour there was a decision over who might survive and who could not be saved.

When he speaks of his rotation at Nasser Hospital, he points out a quarter of casualties were children.

“It was far worse than before,” he said. “The aggressiveness of the fire from the Israeli military made people feel utterly hopeless.”

“One day we had no water to scrub. Another day we didn’t have enough fuel to keep electricity going

Dr Saladin Sawan

Most of the wounded had been shot while trying to collect food at the GHF sites, run by US contractors and the Israeli military, that accounted for nearly a quarter of the hospital’s workload.

“People were desperate for food,” he said. “They were being shot while queueing for aid.”

When the surgeon arrived in August, the hospital’s operating theatres were “on their knees” and there were simply more wounded than the staff could cope with. “Patients died waiting to get into theatre. They were literally lying there, waiting for the operating room to be free.”

Dr Sawan outside Nasser Hospital in Gaza. Photo: Saladin Sawan

One in four children

Not only that, but a quarter of the casualties at Nasser hospital in Khan Younis, southern Gaza, were children, boys in their low teens and many others under 10.

During his first deployment, Dr Sawan used his surgery logbook to disclose that he treated 56 people, of whom 43 were war trauma patients suffering shrapnel injuries. A number of those were children.

But in his shorter two-week stint in August, he conducted 32 war trauma operations, with eight on children and nearly all for gunshot wounds.

Without clean water, surgeons cannot operate, unable to wash their hands, their instruments or the patient’s wounds. There were occasions when for five hours or more there was no water and surgeons were unable to help, as casualties deteriorated and died.

“One day we had no water to scrub,” said the doctor. “Another day we didn’t have enough fuel to keep electricity going and for several days we had no large surgical swabs, so we just tied small ones together to get by. But if there’s no water to wash your hands, you can’t operate, you’d be transmitting infections from one patient to another.”

Perhaps, Dr Sawan argued, if the Israelis could have seen, or at least read, about the inhumanity being inflicted on fellow humans, the violence would not have raged so long and hard. More than 72,000 Palestinians were killed and 171,000 wounded in the conflict.

Dr Sawan operating at a hospital in Syria earlier this year. Photo: Lucy Lyon / David Nott Foundation

Impossible conditions

Ultimately, the number of patients coming through the hospital coupled with the lack of water and electricity meant many did not live through what were survivable wounds. One 13-year-old boy who had suffered gunshot wounds had received “damage control” surgery to stop the bleeding but when they moved him back for a second operation the next day, he went into cardiac arrest and died.

The heat, lack of water and surviving on a just a single small meal a day drove doctors to exhaustion. On one occasion a medic collapsed in the operating theatre.

“We had just started and I had called out for some scissors when this general nurse suddenly slumped on to the table. I called her name but there was no response. She had fainted. That was the level of weakness people had reached.”

On another occasion, the tiny amounts of food meant that a local surgeon was so low on energy that he had to stop his operation.

It was among the many tragedies experienced by Dr Sawan, who was born in Damascus and began his medical training in Aleppo. He completed it after travelling in 1998 to northern England, going on to qualify as a gynaecological and oncology surgeon, working for Britain's National Health Service for two decades.

He is also a general trauma surgeon and part of the elite specialist conflict surgeons from the UK charity, the David Nott Foundation. But in Gaza he was sponsored by Medical Aid for Palestinians, a non-profit organisation based in London.

Israeli soldiers. EPA

Common humanity

What troubled him most about his Gaza assignment was not just the force used, but the disregard for people queuing for food. “Even if soldiers felt threatened, they didn’t take enough care not to hit children or vulnerable people,” he said.

But the 52-year-old believes there was something deeper at play. “Controlling food was used to humiliate Gazans.”

Discussing the issue some months later, Dr Sawan reflected that if journalists had been allowed into Gaza to report on the impact that the violence had on civilians, the intensity of the Israeli aggression could not have been maintained.

Saladin Sawan in Gaza. Photo: Saladin Sawan

That lack of humanity was also difficult to reconcile to the young Israeli soldiers he chatted with as he travelled in a UN convoy from Jordan via the Allenby Bridge crossing.

“Some of them were really pleasant, some were clearly British from their accents and I wondered if any of them came to Gaza and saw the consequences of what they were doing to fellow human beings, would they continue? I don’t think they’d all accept it.”

There was a grim realisation, too, that the violence was carried out by a people who had experienced the holocaust. “Given the history of Jewish suffering, one would have hoped there would be a deeper reluctance to inflict something similar on others,” he said.

Wounded Palestinians in Nasser Hospital in Khan Younis. EPA

Never enough

Throughout both his tours in Gaza, Dr Sawan said he had not seen a Hamas fighter, who the Israelis have alleged used tunnels and rooms below the hospital. “Those around me were all ordinary people.”

When his two-week August tour – which he took as personal annual leave – ended he was aggrieved that there was so much more help needed. “I was sorry that I couldn’t do more. I saw them hungry and I couldn’t feed them.”

But what stayed with him more than the hunger was the relentlessness of the injuries and suffering, and the knowledge that “even when I was working at full capacity, it was never enough”.