The twisted wreckage of an ambulance is displayed at Al Shifa Hospital - the largest hospital in Gaza - by way of memorial to three paramedics who died in the recent conflict. At Al Aqsa Hospital there are gaping holes in the outside walls where paramedics tell me the building was hit. Several ambulances still operating have bullet holes in the windscreens.
I arrived in Gaza with the World Health Organization (WHO) nearly one month after the conflict ended. But the continuing impact on the health system, and on patients, is clear to me.
When I spoke to doctors, pharmacists and paramedics, I realized that as well as damage to medical facilities and casualties among health workers, there are other, less visible, consequences of the conflict on the health system. Patients with chronic diseases, like cancer and diabetes, have missed treatment; the huge drain on supplies from treating the wounded means many critical stocks are exhausted; and chronically ill patients are being referred abroad because the medication they need has run out.
At Al Aqsa Hospital, paramedics told me three of the 25 people in their unit were killed in the conflict. Out of their eight ambulances, three were damaged, with one totally destroyed.
In late July the hospital was damaged by explosives, said Akram Saied, a paramedic who was injured in the attack. "I ran to evacuate people after the first bomb hit. There were children covered in blood and screaming," he said. "Suddenly I felt something hot on my neck and there was blood."
Two metal fragments had lodged in Saied's neck, and a laryngeal nerve was completely severed. He has since returned to work, but says he is still in a lot of pain.
Imad Ali, the manager of the ambulance unit at Al Aqsa Hospital, said during the conflict medical supplies ran short and have not yet been replenished. A lack of latex gloves meant paramedics were often forced to work without them, he said, and a lack of fuel for the ambulances meant transfers from home to hospital for patients with chronic diseases were mostly stopped.
At Al Shifa Hospital, Na'el Skaik, the head of the pharmacy, gave a similar account of the drain on supplies and the difficulties in treating non-trauma patients. "Before the conflict began, hospitals in Gaza worked together to pre-position supplies, sharing vital resources and identifying shortages," Skaik said.
Supplies of certain antibiotics and IV fluids were low, and he knew from previous conflicts that it would take only a few days to exhaust stocks that would normally last a month or more.
"The focus was on the ICU [intensive care unit], and the surgery and emergency departments," he said. "But we didn't expect the war to last so long. All the stocks, all the medicines, were used. We had to request more supplies."
A senior doctor at Al Shifa Hospital told me the facility was often overwhelmed. On one occasion more than 250 injured people arrived at the emergency department within one hour. Sixty of them did not survive.
"The morgue can only accommodate 18 bodies," he said. "We had to put the bodies in a room together and turn up the air-conditioning."
Skaik said despite everything, the oncology department still functioned, but many cancer patients still missed out. "Many people couldn't access their treatment due to the dangers of travelling to the hospital - any car could be bombed on the street," he said.
"These patients were forgotten during the war, and we now have a shortage of some cancer medications," Skaik said. "We refer a lot more of these patients to outside hospitals now because we can no longer treat them in Gaza."
In mid-October WHO published an assessment of the health system in Gaza that highlighted many of these concerns, including ongoing critical shortages of essential medicines, a disproportionate impact on people suffering chronic diseases, and an increase in the demand for referrals outside of Gaza.
The assessment also warned of long-term increased demands on health services by patients who acquired long-term or permanent injuries in the conflict, and the anticipated increase in mental health needs such as PTSD and depression.
WHO is working with the Ministry of Health to rehabilitate and strengthen the health system in Gaza to prevent further unnecessary loss of life.Suggest a correction