Sam Fragoso: You were stationed at Al-Aqsa Hospital in central Gaza, working in partnership with doctors from MAP—the Medical Aid for Palestinians. Upon arriving at the hospital, you described it as, “a semi-functional facility.” What does semi-functional actually look like on that first day?
Dr. Seema Jilani: Well, the reason I say semi functional is because staff were mostly, intermittently able to show up. Supplies were sometimes available, but they were rationed. Patients were being able to be seen, although every day was a different mass casualty and more and more people were filtering into the hospital for a safe haven. It’s not something that, in any other context, would have been what I would label as adequate, proper care, but it was providing its function. As the week went on, it became less and less functional. Doctors and healthcare workers had been displaced, and they were unable to come to work. Communications were patchy, and you didn’t know who would be able to come that day or not.
SF: When you were working, you would tape voice notes on your iPhone. On the first day, what did you tape?
Dr. Jilani: I believe I mentioned that, within the first few hours of us arriving at Al-Aqsa Hospital, I treated a one-year-old boy whose right arm and right leg had been blown off by bombardment. He still had a bloody diaper on but no leg beneath. I treated him on the ground. There were no beds or stretchers available. Next to him, was a man who was taking his agonal last breaths and had been actively dying for the last 24 hours, and there were flies already on him.
One woman, in the meantime, was brought in and declared dead on arrival. And meanwhile, my one year old patient was bleeding into his chest cavity, something we call a hemothorax. He needed a pediatric chest tube. He needed a pediatric blood pressure cuff. He needed a lot of care. And mind you, this would have been a case in the U.S. that would never have seen the ER. It would have been what we call a ‘STAT OR’ case, where they just take him up to the operating room. But because of the complete onslaught of patients coming in, that was unavailable to us. It was complete chaos. No morphine had been given in the total panic. There was no hand soap. There was no disinfectant. The orthopedic surgeon did come, stopped the hemorrhaging, bandaged his stumps, and said, I’m sorry, but we can’t take him to the OR right now. I was completely taken aback, and I said, well, why? He said, there are too many other more life-threatening cases that need those operating theaters right now.
Then I thought to myself, what on earth could possibly be more pressing than a one-year-old with no hand, no leg, who’s going to asphyxiate on his own blood? And I give that example because I do think it’s a microcosm of how completely cataclysmic this situation is.
SF: You’re working in an environment where you and your colleagues have to make quick decisions about who is actively dying and who is slowly dying. You told The New Yorker “that you try and save every single one, but here, if you don’t have the resources, the medicine, the staffing, then you have to triage in a way that prioritizes people who are most likely to live and make a good, solid recovery.” I want to understand that process a little bit. How did you and your colleagues make those assessments? Is there a rubric you were following? Are there certain indicators that suggest one patient is more likely to recover than another patient? How quickly did you have to make those decisions that are literally life or death?
Dr. Jilani: This war changed the calculus of triage completely— and the spectrum on which we would and would not intervene. Of course, you want to save every single patient. Then you have to recalculate and think, what does that mean for that patient? If we save them and they have no access later to physical therapy, occupational therapy, mental health care, educational services, food… how are they going to survive? I learned from my Palestinian colleagues who had been doing this for a lot longer, and they would be the ones to inform us and say, “this case is hopeless, and this one we’ll work on.” I would take their lead and steer on that completely.
SF: Explain how they explained their calculus to you.
Dr. Jilani: It was around resources that were available. So, if we did not have a neurosurgeon in house, then we could not justify working on a patient that needed neurosurgery. Without a neurosurgeon, what are we doing working on this patient in-house? Or maybe they couldn’t get there that day because they themselves were displaced. So, working on a day-to-day basis with a changing sense of resources, they knew what they had and how we could help patients. One of the things I did find comfort in sometimes, until our morphine ran out, was to be able to provide some modicum of dignity and pain relief. When you are out of morphine, it becomes cruel to watch that unfold, and you just get a sense of a very grotesque disregard for life, in terms of dignified death in an emergency room on the floor of a Gaza emergency room.
SF: What does an undignified death look like?
Dr. Jilani: It looks like being on the floor with your arm or leg being blown off, or having such extensive burns over your body that it is charred and the entire emergency room fills with the smell of burnt flesh. You don’t know where your family is. You don’t know if they’re dead or alive. You have no pain control. There was a moment that my colleague in our emergency room had to say, “Whose body part is that?” It was a leg with a boot on that was separated, and they said, “Don’t take that outside. I don’t want children seeing that.” We didn’t even know whose it was, because that’s the level of total devastation.
SF: You’ve said, “As a pediatrician, I expected to not be particularly useful.” Why is that?
Dr. Jilani: I expect that, in a war, that the rules of engagement apply. That means protection of hospitals, protection of civilians, and as much protection as possible of children. The scale and the proportionality of children that I was seeing is unlike any other conflict I have been in. It was staggering. I didn’t expect to see that many children. I think in one of my voice notes, I noted within my line of sight, there were six children that needed urgent or emergent attention. In one case where we had our code room, which is where you actively resuscitate people from the brink of death, basically. Four out of five of our patients were kids under the age of thirteen. That is appalling.
SF: And in your experience of doing this work for twenty years, a complete aberration.
Dr. Jilani: Yes, absolutely.
