Gaza's doctors were building a health system. Then came war.

Dr Sireen Al-Attar was on WhatsApp day and night, communicating with colleagues and pregnant women in the Gaza Strip to make childbirth safer, fellow doctors said. Her work was part of a campaign that began long before the Israel-Hamas war.

The doctor was sleeping in a bed on Oct. 11 with two of her three daughters. Hamas had attacked Israel four days earlier. Anticipating Israeli reprisals, Al-Attar and her three children had left Gaza City to stay with her parents in Bureij, a refugee camp, where they hoped they'd be safer.

There were 21 relatives under one roof. Al-Attar's eldest daughter, Reema, had a mattress on the floor. Before going to sleep, "the last thing I told her was, 'I love you, mom,'" Reema, now 14, told Reuters.

They slept between bombardments. Then the house was hit. Reema woke beneath a cupboard, choking in dust. "I started yelling 'Help, help, Mother, anyone, help, people!'"

No reply came from the bed. Al-Attar was dead, killed in an Israeli airstrike, according to Gaza's health ministry. Reema's 6-year-old sister was seriously injured.

Al-Attar, 39, was one of at least 490 Gazan healthcare workers killed since Israel swore to destroy Hamas in retaliation for its cross-border assault on Oct. 7, according to Gaza's health ministry. She was a specialist doctor, one of a vanguard improving public health for Gaza's fast-growing population before the war, whose deaths have done its health service grave harm.

Operating under an Israeli blockade after Hamas seized control in 2007, the health service in Gaza was fraught with difficulties, including deep-rooted factionalism over who ran Gaza and waves of conflict with Israel. But in some fields the health service had made advances, thanks to investment and support from abroad and the persistence of doctors like Al-Attar, according to a Reuters review of data from the Palestinian health ministry and global aid agencies, and interviews with more than two dozen Gazan and foreign doctors.

One example: Data from the Gaza health ministry shows the enclave's maternal mortality rate had dropped to 17.4 maternal deaths per 100,000 live births in 2022 from 23.4 in 2010, the earliest year for which Gaza-specific data is available. For context, data from the World Health Organization (WHO) shows that in 2020, the most recent year available, 41 out of 100,000 women in Jordan died during or soon after giving birth. In Egypt that number was 17; in Israel, three.

There is no independent mechanism to verify the Hamas-run government's data, which is recognized by the U.N. and used by international health agencies in the same way as government data from other countries. To verify the number of specialist doctors killed and assess the impact of their deaths, Reuters spoke to 10 Gazan doctors in the enclave or abroad, 14 foreign doctors who helped train the specialists, and 10 of their relatives and friends.

Between 2006, when Hamas won power in Gaza, and 2022, Gaza's population jumped by 49% to 2.2 million, health ministry data shows. In that time, the number of general practitioners more than doubled to 1,913, as did the ranks of specialists, to 1,565.

That was helped by an influx of foreign support, including from doctors in Israel. A Reuters tally of public records and inquiries to U.N. officials show at least $2 billion was allocated to healthcare in Gaza over that time by the Gazan ministry of health and U.N. aid agencies alone.

Specialist doctors like Al-Attar were part of a strategic effort by Hamas to build a self-sufficient health system for Gaza, from burn care to cancer diagnosis and kidney treatment, Gaza's first health minister told Reuters.

In the current war, 55 specialist doctors in Gaza have been killed, according to information from the ministry of health, as well as relatives, colleagues and friends. Reuters could not independently verify the circumstances of their deaths.

That works out at nearly 4% of Gazan specialists. In some specialties with small cadres of doctors, the losses are stark. The enclave had just three kidney specialists before the war – one has been killed and the other fled abroad, Reuters learned.

Hamas and its allies have long argued that Israel has a goal of destroying its health system, an allegation Israel's military denies.

Reuters found that seven of the 55 specialists were killed in hospitals. As many as 23 were killed when they were away from work. Reuters couldn't find clear information on where the remainder died.

With each specialist killed, Gaza has lost a network of knowledge and human connections, blows more enduring than those borne by most of the area's 35 hospitals since Oct. 7, the doctors and experts said. The killing of even one doctor could cripple the services they led where specialists were few.

Reuters chronicled the struggle of Al-Attar and two other specialist doctors in Gaza to train and work under the Israeli embargo of the enclave, and examined how they helped improve healthcare there.

"It's a massive loss," said Dr Deborah Harrington, a British obstetrician who helped instruct Al-Attar and others. "The healthcare system can ill afford to lose these experts." Rebuilding the system, Harrington said, "is going to go into decades."

Hamas did not respond to a request for comment.

The Israel Defense Forces (IDF) did not comment on the deaths of the doctors named in this story. But it said in a statement to Reuters that the IDF has "overwhelming and irrefutable" evidence that Hamas used hospitals and medical infrastructure as cover for "terror purposes."

Throughout the war, the Israeli army has released what it says is evidence Hamas made military use of medical facilities, including weapons it said it seized in hospitals, a video of the interrogation of a detained hospital director and a tunnel near Al Shifa hospital that the IDF says was a command post for Hamas fighters. Hamas denies these claims.

"The IDF is not interested in medical staff vis-a-vis their roles as medical professionals, but due to their potential involvement in Hamas terror," it said, speaking generally.

Reuters was unable to independently verify the competing claims made by both sides about the involvement of Gaza's health system in the current conflict.

More than 36,000 Palestinians and nearly 1,500 Israelis have been killed since Oct. 7, Gazan and Israeli tallies show. Israel says around 120 people abducted during Hamas's attack are still being held hostage in Gaza.

"NEW GENERATION OF PROFESSIONALS"

Around 80% of the Palestinians living in Gaza are refugees who were expelled or fled their homes during the 1948 war surrounding Israel's creation, and their descendants. Al-Attar's story parallels that of Gaza's healthcare system amid isolation, war and intra-Palestinian political strife.

Born in 1984, she started medical school in 2002, when Gaza depended for advanced medical treatment on hospitals in Israel and other nearby states. At that time the enclave had fewer than 30 beds in special care units, according to a 2012 report by the Center for Strategic and International Studies (CSIS).

Hamas, a militant Islamist group whose founding charter calls for the destruction of Israel, secured control of Gaza in 2007 after bloody post-election fighting with Fatah, the ruling party of the Palestinian Authority based in Ramallah in the West Bank. The takeover resulted in two de facto governments in Ramallah and Gaza, each with ministries of health.

Gaza's health services were isolated from the Ramallah ministry, which began restricting funds to the enclave. Israel closed Gaza's borders with Egypt's help, curtailed people's movements and access to medical supplies, and started responding to Hamas attacks with military campaigns.

The Palestinian Authority had health clinics reserved for its employees or security personnel, most of them Fatah members, the CSIS report said; Hamas aimed to retool these in Gaza to recruit and retain its own loyalists.

Dr Basem Naim, the first health minister under Hamas rule, confirmed he replaced medical leaders but said that before Hamas came to power, "a lot of good doctors and nurses were denied a job in the Ministry of Health ... because they were affiliated to other political groups other than Fatah." Hamas' goal was to professionalize the service, he said. It began seeking specialist training to create what he called a "new generation of professionals" for a health system to support a Palestinian state.

Naim, in office until 2012, now acts as a Hamas spokesman from Doha, Qatar. Abed Doleh, a spokesperson for Fatah, denied allegations its members received preferential treatment and said it made healthcare available to all Palestinians. The Ramallah ministry did not respond to requests for comment.

In his first year, Naim said, the ministry paid $110 million to hospitals in Israel, Egypt and Jordan for the treatment of Palestinians. But Hamas wanted to invest in its own doctors instead.

In 2008, medical student Al-Attar graduated from the Gaza branch of Al-Quds University with top grades. That won her the enclave's only scholarship for specialty training in obstetrics and gynecology – in Amman, Jordan. She was one of about 140 doctors whom Naim said the Gaza ministry sent for training there.

"We fought with all of our force and all our capabilities to get some of the young, freshly graduated doctors outside the country, to get a very professional training," said Naim, himself a surgeon.

Pregnant with Reema as she prepared to take up the scholarship, Al-Attar had direct experience of the Israeli blockade. She needed to give birth in Jordan or delay her studies while waiting for permits to travel with the child, her husband, Dr Wajdy Jarbou, told Reuters.

Al-Attar had difficulty getting out. In April 2010, she made it to a hospital in Jordan less than 24 hours before Reema was born, Jarbou said.

She had left a system running under a siege mentality. Isolated by Israel and Fatah, Hamas was expanding informal social networks to tighten its grip on Gaza, smuggling goods from Egypt through tunnels, fostering charities, imposing taxes on the population and seeking aid from abroad.

"UNEXPECTED SUPPORT"

By 2022, Gaza had 3,412 hospital beds, almost a 70% increase from 2009, the earliest year for which health ministry data is available. That amounted to nearly 15.5 beds per 10,000 people – more than in Egypt, Jordan and Syria, but about half the Israeli total, according to the latest WHO data.

Gaza was helped by governments and charities abroad including the European Union, Indonesia, Kuwait, Turkey, the United Arab Emirates, and the United Nations.

No clear data is available on how much all have spent. The records Reuters was able to review add up to a minimum of $2.2 billion since 2006, including almost $740 million from the U.N. children's agency UNICEF and population fund UNFPA.

The main aid provider in Gaza is the United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA). Its reports do not say how much of the $4 billion it has dedicated to Gaza was spent on health, but they do show this was at least $75 million. UNRWA didn't respond to questions about its medical spending.

Reuters could not access all the Gaza health ministry's spending records. According to its public reports, its total spending was $1.4 billion between 2015 and 2022.

"One paradoxical consequence of the siege is that actually the health sector has witnessed an expansion," said Cambridge University social scientist Mona Jebril, who published a 138-page study of Gaza's health system in 2021. She attributed the growth to a range of factors, saying a well-functioning healthcare system was essential for Hamas's survival.

Physicians in Israel also helped. Jaffa-based nonprofit Physicians for Human Rights Israel (PHRI) began working with Gaza's health ministry in 2009, said its head, Guy Shalev.

From 2010 until the war started, PHRI sent Israeli specialist doctors of Palestinian origin to Gaza on regular trips to train doctors on advanced medical procedures.

The Israeli physicians received "unexpected support and welcome from the ministry" run by Hamas, Shalev told Reuters. "Our impression was they were super motivated, in terms of making it work even in these very impossible conditions, getting the public health system to operate properly and provide for the people."

The Israeli organization's main contact in Gaza's health ministry was its director general, Dr Munir Al-Bursh. The ministry said Al-Bursh was injured in a Dec. 21 Israeli airstrike on his home in Jabalia in northern Gaza – a strike that killed his daughter.

Al-Bursh's wife said he is still recovering and so was not available for comment.

"HELL WITH THE PROTOCOL"

In 2016, Al-Attar and her husband returned to Gaza to work for the health ministry. Ministry data shows its hospitals then handled two-thirds of surgeries in Gaza, performing 66,051 procedures – an increase of nearly 13% since 2010.

She joined a health ministry project to lower maternal mortality, passing on skills she learned in Jordan and training doctors – many male – how to diagnose lung embolism and deep vein thrombosis, which can be fatal.

"She was the youngest, and the new one," said her colleague and friend Dr Sana Najjar.

Daily life was characterized by power outages, slow internet, political instability and cycles of conflict. The system lacked stable supplies and still needed to refer certain patients to hospitals in Israel and elsewhere.

"We couldn't afford fuel for her to get to work," said her husband, Dr Jarbou. "She was – and not just her ... subjected to many crises like this."

He had also received specialist training in Jordan, as a radiologist. But in 2020, like many doctors in Gaza, he moved abroad for a better salary. He spoke to Reuters from his home in Oman, where Reema and her sisters joined him after their mother's death.

In 2017, Al-Attar joined a study across four of Gaza's hospitals, co-writing a paper published in The Lancet in 2021. It found that hospitals where newborns were thoroughly dried, received immediate skin-to-skin contact and enjoyed early breastfeeding had improved outcomes.

But she became frustrated with the ministry's bureaucracy, which she felt too often left pregnant women at risk. She believed hospital procedures were not flexible enough to allow swift intervention when needed and poor communication between hospital departments also hampered care, colleagues said.

"She was feeling resistance everywhere," said her friend, Najjar. In 2020, she moved to a more reliably paid role at UNRWA, the UN aid agency. The Gaza health ministry did not respond to a request for comment on those points.

Across UNRWA's 22 health centers, Al-Attar was one of just three obstetric specialists, said Najjar, a family health officer at UNRWA.

Najjar said Al-Attar supported her at a center she ran in the southern city of Khan Younis, using her knowledge and connections to intervene for women at risk. She would personally offer to see each patient and would follow up through messages and calls.

"She said, 'Hell with the protocol, hell with the schedule, refer to me any case,'" said Najjar. Al-Attar would be assigned 25 cases but see up to 50, and stay late to see patients.

Al-Attar also helped with guidance on whether refugees should be referred by UNRWA for Cesarean section – a more lucrative procedure for hospitals and thus liable to overuse, said Najjar. Preventing such surgeries when unnecessary can reduce risk for mothers and babies, health officials say.

Al-Attar herself had help from abroad. She was working to develop multidisciplinary training, bringing in midwives and doctors of all levels, said consultant Harrington, who works at Oxford University Hospital. Harrington and others visited Gaza annually since 2016 to help with training, funded by charities including UK non-profit Medical Aid for Palestinians (MAP).

"Sireen was making the care of women better," she said. "And she had gotten other people on board."

SKIN GRAFTS VIA SKYPE

Gaza's population was growing, increasing demand for obstetrics specialists. But it also needed doctors specialized in injury.

During a 2008-2009 war, doctors faced wounds caused by Israeli smokescreen munitions containing white phosphorus – a material that ignites instantly on contact with oxygen, sticks to surfaces such as skin and clothing, and burns deep into the flesh. Israel said it used the chemical in accordance with international regulations.

Patients who had more than 20% of their total body area burned died for lack of specialist facilities and expertise, doctors said. In Europe and the U.S., patients with even 90% burns could be helped to survive.

So Gaza's medics sought training in burns.

Dr Medhat Saidam had attended medical school in Kazakhstan and returned to Gaza in the early 2000s. Most Thursdays in 2012 and 2013, he was one of a group of six surgeons and four nurses who would join a 6 a.m. Skype call from a room in Al Shifa Hospital in Gaza City.

On the line from Britain, where it was 4 a.m., Syria-born plastic surgeon Dr Ali Ghanem would lead the students in hands-on simulations of skin grafts and other training.

It was part of a distance-learning program on burn care at Queen Mary University of London. The blockade made it impossible for Gazan medics to attend on site.

"The Gazan cohort was so eager, extremely thirsty," Ghanem said. "They developed their skills and grew very, very fast."

Saidam focused on burns, limb reconstruction, and cleft lip and palate. He went on to mentor colleagues at Al Shifa on burn management, "like the big brother or the father of everyone else in the plastic surgery department," recalled Dr Hasan Eljaish, who worked with him for 15 years there.

Gaza had only five practicing plastic surgeons with the same experience and training, Eljaish said.

The enclave was training more. Medical charity Medecins Sans Frontieres (MSF) helped, running clinics across Gaza and a burn care program at Al Shifa. To handle such burns involves a combination of specialisms, said Emmanuel Massart, the head of Gaza operations for MSF's Belgian arm.

By late 2023, an MSF limb reconstruction center at another hospital, Al Awda, was treating more than 100 patients, each over a period of several years, Massart said.

"You really, really struggle to find specialists that can do that," he said.

On Oct. 13, plastic surgeon Saidam, who had three daughters and a son, was on call at Al Shifa but asked Eljaish to cover while he left to help his sister evacuate her home.

The following day, ambulance workers extracted his body from beneath the rubble of his home in the Tal Al-Hawa neighborhood of Gaza City after an Israeli airstrike around 1 a.m., his colleagues said.

Eljaish said he saw Saidam's body brought into the Shifa morgue.

Before Saidam left the hospital, "last I remember, he was playing with my son Ali," who was 2.

In April, another of the five main plastic surgeons, Ahmad al-Maqadma, was killed with his mother in an IDF raid on Al Shifa hospital, friends and colleagues said.

Three of the five remain.

3D-PRINTED SUPPLIES

The day Hamas attacked Israel, kidney specialist Dr Hammam Alloh contacted Dr Tarek Loubani, a Canada-based physician and medical director of the Glia Project, a group that makes medical devices for conflict zones.

Alloh, 36, was looking for help with equipment for dialysis machinery. He had been treating kidney patients in Gaza since 2020. When they spoke, Loubani said, Alloh recalled a previous war in 2014: He remembered patients had died because hospitals could not obtain equipment such as dialyzers, tubing, needles, cartridges and bags.

Alloh asked what equipment could be made in Gaza using 3D-printing, Loubani told Reuters. "Unfortunately, the answer was 'not very much in the context of dialysis.'"

In 2007, when Israel's blockade began, Gaza had no certified kidney experts, doctors said.

By October 2023, it had three, including Alloh. There were 1,061 patients on dialysis treatment at six hospitals, according to the WHO.

Since the war started, Israel and Egypt have granted permission for 153 of Gaza's dialysis patients to continue treatment abroad, though not all have been able to leave, a WHO spokesperson told Reuters.

With much dialysis equipment destroyed or damaged in the fighting, 760 patients were being treated in two facilities as of April 25, the WHO spokesperson said. There they receive only partial care, which makes them prone to disease and worsens their condition, the spokesperson said.

The remainder have not been reporting for dialysis. It is possible that they are dead, he said.

Less than a month before the Hamas attack, Alloh attended a meeting to spearhead a program for Gazan doctors to receive specialist training in nephrology in Gaza instead of abroad.

A longer-term goal was to establish a kidney transplant program, three doctors familiar with the plans told Reuters. Transplants were preferable because the blockade made dialysis supplies unreliable.

Alloh was "really thinking huge, like, 'We're going to get nephrology to world-class levels,'" recalled Loubani.

But five weeks after the kidney doctor contacted Loubani, Alloh was killed in an airstrike on his in-laws' house near Al Shifa Hospital, relatives and colleagues said.

Another kidney specialist left Gaza in January. Now, there is one.