GAZA CITY, Gaza — Dr. Ehab al Ramlawy fanned beads of sweat off his face with the shiny black X-ray slide in the sweltering, dimly lit emergency room of Gaza City's al Shifa Hospital.
Sleeves rolled up over sweaty forearms, he leaned over one patient's paperwork while he listened to a list of symptoms from the next. Behind them milled a restless crowd of the sick and infirm, bathed in the light from a nearby window, anxiously waiting for a piece of his time.
Al Shifa is the biggest hospital in the Gaza Strip, but a years-long Israeli and Egyptian economic blockade and Palestinian political infighting between the militant Islamist group Hamas, which rules Gaza, and the Palestinian Authority in the West Bank have left it strapped for resources.
Its emergency room treats 400 people a day in one large, rundown room with 11 beds and a chronic shortage of medicine. Rolling blackouts leave it dependent on diesel-guzzling generators that run for more than 12 hours a day, and most departments have few lights and no air conditioning in the heat of summer. Advanced equipment lies unused and useless, crippled by a lack of spare parts.
"We lack equipment and we lack many types of medicine," said Ayman al Sohbani, the director of the ER. During Israel's January 2009 incursion into Gaza, he said, the facility was treating 300 additional patients a day, even after an Israeli air strike nearby blew out the hospitals' windows.
Israel charged at the time that Hamas fighters operated in and around the hospital and maintained a bunker below the building, an allegation that's never been proved or disproved.
"We manage to work, even if we do not have the things we regularly need," Sohbani said. "Sometimes we have something, and sometimes we don't; sometimes we fix things, and sometimes we can't."
Officials in Gaza's Ministry of Health say that al Shifa's problems reflect those at hospitals and clinics across the small territory of 1.5 million inhabitants that's been cut off from the outside world by a blockade Israel and Egypt imposed after Hamas took power from the rival, Western-backed Palestinian Authority in 2007.
Gaza health officials charge that the Palestinian Authority hoards medicine and supplies and is unresponsive to their needs. The Palestinian Authority denies the charge, and the World Health Organization greets it with skepticism. The WHO says Gaza's government is too poor to buy supplies and blames any supply holdups on the two Palestinian factions' distrust of each other and their inability to cooperate.
Under the terms of the blockade, machine parts that could serve a military purpose and construction materials such as steel and cement aren't allowed into Gaza.
These restrictions often bar spare parts, and they've left the Ministry of Health unable to repair damaged facilities, complete an expansion of Shifa that's been unfinished since 2006, or repair broken or malfunctioning equipment, said Ministry spokesman Ahmed al Ashi.
They also have prevented Gaza authorities from repairing all the damage to the Strip's electrical grid caused by Israeli air strikes since 2006, so daily rolling blackouts are a fixture of life.
Israel eased its restrictions on imports of some spare parts after its June commando raid on a Turkish ship that was attempting to run the blockade of Gaza in which nine activists were killed. Nevertheless, shortages persist, and officials at Gaza's economy ministry say the outright ban has been replaced by a complex entrance procedure that subjects every shipment to an Israeli review process that can last three weeks.
"Sometimes they answer positively, and sometimes they do not answer at all," said Hatem Oweida, the ministry's director general.
Further complicating matters, only one Israel-Gaza border crossing, Kerem Shalom, is open for cargo. Last month, the Israeli Coordination and Liaison Administration increased the number of trucks that are allowed to unload at the crossing to 210 a day from 140.
However, Oweida said, that's had little effect. "It's as if they never eased the siege," he said.
The unreliable electrical supply has left al Shifa at the mercy of its backup generators for 12 or more hours a day, said hospital director Hussein Ashour.
The generators take several seconds to kick in after the power dies, damaging sensitive machines such as the CT scan, MRI and kidney dialysis equipment, which are forced to shut down abruptly and then restart. Water pumps stop. So does the pharmacy's air conditioner, risking damage to medicine such as a small and precious cache of cancer treatments worth millions.
There's also a constant fear that the overworked generators may fail one day. That happened on July 22, when the generators powering the operating theater and maternity ward at al Shifa and a second hospital in the Khan Younis refugee camp failed to activate during a routine blackout.
"The generators totally stopped for three hours," Ashi said. "They had to sew patients on the operating table back up and reschedule their . . . appointments."
For patients on ventilators, blackouts can be fatal.
Gaza's health ministry declared a state of emergency Sunday after the strip's sole power plant shut down Saturday due to a lack of fuel. The shutdown "could lead to dozens of deaths, including children and patients in critical condition in the operating room," Muawiya Hasanein, the ministry's director of emergencies, told the Palestinian Ma'an news agency.
Ashi said that Gaza is entitled to 40 percent of all the medical supplies in the Palestinian Authority, but that since January, the Palestinian Authority in Ramallah has provided only 10 percent of that.
"When we say we need medicines in a week, Israel gives us permission for them to enter after one month. When we get the approval, Ramallah sends only part of our order or nothing at all," he said. "This means that both sides are participating in the siege. Everyone plays a role: Israel by its blockade, and Ramallah by cutting off the supplies that we need."
Ghassan Khatib, a spokesman for the Palestinian Authority in Ramallah, said that 50 percent to 60 percent of the Palestinian Authority's budget is devoted to providing services in Gaza, including health services. "I doubt their figures are correct," he said.
The shortfall of supplies is a real problem, said Mahmoud Zahar, the director of the Gaza office of the World Health Organization. However, he said that Gaza officials are off the mark about both its severity and its causes.
Gaza's total share of medical supplies is worth $5.3 million each year, Zahar said, but since the start of this year it's received "no more than 30 percent" of that.
The problem, however, isn't Palestinian Authority misdeeds or an Israeli ban, Zahar said. Instead, after three years of siege and political infighting, Gaza's Hamas government is too poor to purchase medical supplies and too alienated from the Palestinian government in the West Bank to divvy up humanitarian aid effectively.
Faced with so few health options, many in Gaza are looking abroad. Egypt opened its Rafah border crossing after Israel's deadly June raid of the Turkish ship, and the WHO says the flow of patients to Egypt is thought to have doubled.
The WHO estimates that every month, 1,000 Gazans apply for permits to travel elsewhere for medical care. Some 80 percent are approved eventually, but Physicians for Human Rights has charged that in some cases Israeli authorities have pressured patients to provide information or collaborate in exchange for permits.
"The rest either have their files reviewed, or they seek alternative care, or they die," Zahar said. The WHO has documented as many as 40 cases of people who died while they were awaiting permission to seek treatment in Israeli hospitals, he said.
Patients aren't the only ones who try to leave. Many doctors also hope to get out. At al Shifa, Ramlawy rattles off the names of a half-dozen colleagues who've left to work or study overseas. Next month, he'll emigrate to Australia.
"I learned to be a doctor to serve my people, not to leave the country," he said. "But I can't take the general situation in Gaza. The serious lack of everything — medical supplies, equipment, just everything."
(Stack is a McClatchy special correspondent.)
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