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Gaza - Autumn 2006 --- The thin and limpid crescent lies on its back in a clear sky. If it does not reappear tomorrow then Ramadan will end. A 'drone' can be heard above the amplified recitations of the Quran, but it cannot be seen.


On the third floor of the battered and very busy Shifa hospital here in Gaza city lies a 9 yr old boy in his fourth month of recovery. Saad is a sad and frightened boy. He has lost all the muscle from the front of his left thigh. The shape of his femur can be seen in its entirety beneath the skilful skin grafting. There is just a twitch of motion in the foot. Most parts of his young body are scarred. There are many of punctate type, including on his face. There is a colostomy which will probably be permanent because his bowels were badly damaged. The tracheostomy has healed, and the pleural fistula is well on that way.

Boy With Badly Damaged Leg Following the capture of Corporal Gilad Shalit and the shooting dead of two of his comrades by a Palestinian guerrilla unit on the 25th of June, 'Operation Summer Rains' was set in place by the occupier headed by Mr Olmert. This was on top of the medieval siege which started at the end of March and in which Israel was joined by the twenty-five nations of the EU, the US, Canada and Japan. This was the reward for scrupulous elections and a Hamas majority of 72 seats in a legislature of 135. There are no ends to the ingenuity of collective punishment. In November 2005, the 1.4 million population had been terrified by sonic booms at roof top level. British Aerospace should be rightly proud of the head-up cockpit display in those F16s which so enhanced the aeronautical skills of the IAF as they smashed sleep and windows in Gaza prison. Anyway, post-Shalit there was an explosion of state assassination from the air. In early July, Saad was in the street when hell was loosed from a drone. Two people were killed immediately and two others died shortly after admission because their injuries were so severe. So Saad is a living remnant of electronic and explosive wizardry.

The surgeons of El Shifa have many high resolution photographs of the surviving and the dead. These are not correlated with the target sites and neither are there names or numbers of the victims. However, in those post-Shalit weeks they saw over 250 deaths including 57 children. In such conditions of chaos, grief and horror, record keeping is relegated.

The injuries shown in these digital pictures were categorised as follows:-

1. Widespread burning and flaying ie no skin/fat and with muscle exposed. Some of the burns appeared to be the result of high temperature flash burns. Saad is a living example.

Agents - thermobaric missile – Hellfire AGM-114N - plus incendiary material.

2. Amputation by blast at the root of the legs or the lower torso.

Agent - the Palestinians believe there is a bomb or a missile with a projecting lance which causes detonation above the ground.

3. Less severe injury of the skin – possibly some burning – but with rupture of soft viscera. Some were admitted dead in all probability, but others went on to exploration. Ruptured livers, blood in the chest cavity etc. Death was usual.

Agent - shock wave – push and pull of a thermobaric missile.

4. Entry wounds like those of shrapnel. Sometimes limbs without a blood supply. X-rays showed no retained metal. Explored – burnt, but not charred tissue, with complex branching extensions. Very difficult to expose all the abnormal tissue and to excise it. Therefore a high infection rate, higher amputation rate and a higher mortality rate.

Agents – thermobaric weapon containing incendiary material. Phosphorus or uranium are possibilities.

The doctors noted that whatever missiles or bombs were being used, they were more lethal and the injuries were often terrible. The amputation and death rates in hospital were very different from what they had seen before. They were well used to dealing with the results of shrapnel and high explosive injury before this 'epidemic'.

Some have cast doubt on the provenance of these photographs. They must offer explanations. Certainly Saad would appear to be a survivor of the first type of injury listed but his injuries were a little less grotesque.

Two target were sites were visited. The first appeared to be unexceptional aside from the killing.

The second involved a missile that entered a house during the night. One person was killed and twenty-four injured. A girl of three was in a hip spica plaster. It was understood she had a fracture of a femur from falling masonry. A young man had three punctate burns, two being black. A grandmother had a blackened tip of her left index finger. The bone was injured in some way. When the missile had struck over a week before a liquid was seen. This had a very unpleasant smell and it was this which caused the burns. The smell was still coming out of the ground which had been levelled for re-building. Parts of the missile casing were seen. A pear shaped and very heavy lump of metal had been gathered too.
The people in the remnants of Palestine are in a special category in international law. The majority are displaced persons and thus they are due special protection.

Might the nations of the world, sixty years from the Nuremberg Rules, insist upon international law and observe the universal norms of humanity. The killing and maiming must stop forthwith – everywhere.

A protocol for the investigation of all military attacks in Gaza has been put forward. A scintillation counter was ordered by the physics department at the Islamic University in Gaza but its importation had been barred. Outside experts will be needed to re-inforce the inspection team in the early stages.

Saad means - 'happiness'. Oh would that little Saad be made whole and happy again.

Gentle Jesus meek and mild, look down upon this little child - in this the Holy Land.

Dr Al Saqqa and his colleagues of the El Shifa hospital are thanked warmly for providing the accounts and photographs of these injuries and deaths.

David Halpin FRCS Trauma and orthopaedic surgeon. He founded the Dove and the Dolphin Charity 1100119, one of the aims of which is to promote the health and welfare of Palestinian children.