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GAZA: At Shifa hospital in the Gaza Strip, nothing is sterilized, so Dr. Jamal Salha and other surgeons wash their instruments in soap. Infections are rampant. The stench of medical waste is overwhelming. And flies are everywhere.

Without painkillers, patients moan while lying on metal beds lining the corridors. There’s no electricity and no ventilation amid searing heat, leaving anxious visitors to fan bedridden relatives with pieces of cardboard.

Shifa, once the largest hospital in Gaza and the cornerstone of its health care system, is a shell of its former self after 22 months of war. The hospital complex the size of seven soccer fields has been devastated by frequent bombings, two Israeli raids and blockades on food, medicine and equipment. Its exhausted staff works around the clock to save lives.

“It is so bad, no one can imagine,” said Salha, a 27-year-old neurosurgeon who, like countless doctors in Gaza, trained at Shifa after medical school and hopes to end his career there.

But the future is hard to think about when the present is all-consuming. Salha and other doctors are overwhelmed by a wartime caseload that shows no sign of easing. It has gotten more challenging in recent weeks as patients’ bodies wither from rampant malnutrition.

Shifa was initially part of a British military post when it opened in 1946. It developed over the years to boast Gaza’s largest specialized surgery department, with over 21 operating rooms. Now, there are only three, and they barely function.

Because Shifa’s operating rooms are always full, surgeries are also performed in the emergency room, and some of the wounded must be turned away. Bombed-out buildings loom over a courtyard filled with patients and surrounded by mounds of rubble.

Salha fled northern Gaza at the start of the war — and only returned to Shifa at the beginning of this year. While working at another extremely busy hospital in central Gaza, he kept tabs on Shifa’s worsening condition.

“I had seen pictures,” he said. “But when I first got back, I didn’t want to enter.”

A young doctor and a war

After graduating from medical school in 2022, Salha spent a year training at Shifa. That is when he and a friend, Bilal, decided to specialize in neurosurgery.

But everything changed on Oct. 7, 2023, when Hamas attacked Israel and Israel’s retaliatory campaign began.

For the first few weeks of the war, Salha was an intern at Shifa. Because Israel had cut off Gaza’s Internet service, one of Salha’s jobs was to bring scans to doctors around the complex. He had to navigate through thousands of displaced people sheltering there and run up and down stairwells when elevators stopped working.

Once Israeli troops moved into northern Gaza, he and has family left. Bilal, who stayed in Gaza City, was killed a few months later, Salha said.

Not long after Salha left, Israeli forces raided Shifa for the first time in November 2023.

Israel said the hospital served as a major Hamas command and control center. But it provided little evidence beyond a single tunnel with two small rooms under the facility.

It made similar arguments when raiding and striking medical facilities across Gaza even as casualties from the war mounted. Israel says it makes every effort to deliver medical supplies and avoid harming civilians.

Under international law, hospitals lose their protected status if they are used for military purposes. Hamas has denied using hospitals for military purposes, though its security personnel can often be seen inside them and they have placed parts of hospitals off limits to the public.

Israeli forces returned to Shifa in March 2024, igniting two weeks of fighting in which the military said it killed some 200 militants who had regrouped there.

The hospital was left in ruins. The World Health Organization said three hospital buildings were extensively damaged and that its oxygen plant and most equipment were destroyed, including 14 baby incubators.

While all this was going on, Salha worked at a hospital in central Gaza, where he performed over 200 surgeries and procedures, including dozens of operations on fractured skulls. Some surgeons spend a lifetime without ever seeing one.

When he returned to Shifa as a neurosurgeon resident, the buildings he used to run between — some had been rehabilitated — felt haunted.

“They destroyed all our memories,” he said.

A shrunken hospital is stretched to its limits

Shifa once had 700 beds. Today there are roughly 200, and nearly as many patients end up on mattresses on the floor, the hospital manager said. Some beds are set up in storage rooms, or in tents. An extra 100 beds, and an additional three surgery rooms, are rented out from a nearby facility.

The hospital once employed 1,600 doctors and nurses. Now there about half as many, according to Shifa’s administrative manager, Rami Mohana. With Gaza beset by extreme food insecurity, the hospital can no longer feed its staff, and many workers fled to help their families survive. Those who remain are rarely paid.

On a recent morning, in a storage room-turned-patient ward, Salha checked up on Mosab Al-Dibs, a 14-year-old boy suffering from a severe head injury and malnutrition.

“Look how bad things have gotten?” Salha said, pulling at Al-Dibs’ frail arm.

Al-Dibs’ mother, Shahinez, was despondent. “We’ve known Shifa since we were kids, whoever goes to it will be cured,” she said. “Now anyone who goes to it is lost. There’s no medicine, no serums. It’s a hospital in name only.”

There are shortages of basic supplies, like gauze, so patients’ bandages are changed infrequently. Gel foams that stop bleeding are rationed.

Shifa’s three CT scan machines were destroyed during Israeli raids, Mohana said, so patients are sent to another nearby hospital if they need one. Israel has not approved replacing the CT scanners, he said.

Patients wait for hours — and sometimes days — as surgeons prioritize their caseload or as they arrange scans. Some patients have died while waiting, Salha said.

After months without a pneumatic surgical drill to cut through bones, Shifa finally got one. But the blades were missing, and spare parts were not available, Salha said.

″So instead of 10 minutes, it could take over an hour just to cut the skull bones,” he said. “It leaves us exhausted and endangers the life of the patient.”

When asked by The Associated Press about equipment shortages at Shifa, the Israeli military agency in charge of aid coordination, COGAT, did not address the question. It said the military ‘’consistently and continuously enables the continued functioning of medical services through aid organizations and the international community.″

Unforgettable moments

From his time at the hospital in central Gaza, Salha can’t shake the memory of the woman in her 20s who arrived with a curable brain hemorrhage. The hospital wouldn’t admit her because there were no beds available in the intensive care unit.

He had wanted to take her in an ambulance to another hospital, but because of the danger of coming under Israeli attack, no technician would go with him to operate her ventilator.

“I had to tell her family that we will have to leave her to die,” he said.

Other stories have happier endings.

When a girl bleeding from her head arrived at Shifa, Salha’s colleague stopped it with his hand until a gel foam was secured. The girl, who had temporarily lost her vision, greeted Salha after her successful recovery.

“Her vision was better than mine,” the bespectacled Salha said, breaking a smile.

“Sometimes it seems we are living in a stupor. We deal with patients in our sleep and after a while, we wake up and ask: what just happened?”