How many roads must a man walk down

Before you can call him a man?

….

Yes, and how many times must the cannonballs fly

Before they're forever banned?

…

Yes, and how many times must a man look up

Before he can see the sky?

And how many ears must one man have

Before he can hear people cry?

Yes, and how many deaths will it take 'til he knows

That too many people have died?

The answer, my friend, is blowin' in the wind

The answer is blowin' in the wind

Bob Dylan, 1962

Our journal started 2023 with the promise that we would plant a tree in each issue, a virtual tree made of paperless pages, as a reminder of the importance of preserving the precious life of our planet [1].

We end the year in deep sadness, more conscious than ever before that no tree will lessen the tragedy of the loss of a single child, be it in Israel, in Gaza, in Ukraine, in Sudan, or in Myanmar, victim of one of the many endless wars being waged, reported on the front page of the newspapers, or completely forgotten [2].

Should it matter to us as physicians? Should we be borderless defenders of the life of our planet and of humankind, or should we be enlightened scientists, estranged from daily events?

Each and none of the above answers is probably the right one.

Yet hope should never die. This is why the last editorial of 2023 is based on an interview with two colleagues, a nephrologist and a vascular surgeon, who were planning to leave for a humanitarian mission in one of Gaza’s children’s hospitals, where a dialysis ward was recently opened. The mission was cancelled after October 7th.

Hafedh’s family is from Tunisia, and he is Muslim; Alexandre is French, and his father’s family is Jewish, his mother’s family is Catholic; the hospital is a part of the PCRF (Palestine Children's Relief Fund) and is US funded, based upon voluntary donations [3]. When I asked Alexandre why he was engaged in this mission, he answered it was because he is a good surgeon and likes to be useful. He said his family background had never been a problem when he worked in Palestine, while he still felt furious recalling how Hafedh had once been mistreated when they had arrived together in Jerusalem. When I asked Hafedh, however, he smiled, waved his hand as though he were swatting away a fly, and said he had completely forgotten.

Neither Alexandre nor Hafedh know much about what is happening in the hospitals where they were supposed to work, or what the destiny of their young patients and of their local colleagues has been. All they know is that the lack of water and electricity has presumably made dialysis impossible, and that the patients’ survival has been made impossible, too. The situation of dialysis patients was already critical in Gaza, as well as in Palestine in general. “There were over 1200 patients on haemodialysis in Gaza before the war started” Hafedh reported. Alexandre’s tasks were to teach local surgeons how to make and repair vascular accesses; Hafedh taught monitoring, fistula care, and how to interpret the alarms and the data from the machine. “I do not go there to train and perform surgical procedures; I watch, advise and intervene only when needed”, Alexandre said. His teaching and operating days must be long.

“When we started, dialysis catheters were too often in the subclavian vein, but after teaching, the jugular vein is now chosen”. In the absence of interventional radiologists, they taught nurses how to use a Doppler.

The situation was already critical, Hafedh said: “Most of the patients come with a family member who keeps an eye on them during dialysis and is able to manage the most common alarms of the dialysis machine; they call a nurse only when they cannot solve the problem”. There are too few nurses, sometimes one for six or more patients, and in some settings they may end up working for several days in a row without being able to go home, as roads are often blocked, and getting to a hospital is difficult both for the patients who need to be treated and the nurses who need to take care of them.

The largest dialysis facility in Gaza used to work 24 h a day, in 4 shifts, due to the shortage of dialysis machines. Hafedh reports that, because even before the war water and energy supplies were often interrupted, the hospital had power generators and 3000-L storage tanks so they would not be left without electricity and water. “But they are unlikely to be sufficient for long.”

“I suppose that very few people know that there were so many dialysis patients in Gaza,” Hafedh said. This is indeed true. I used to be one of the many. Now, from the messages Hafedh received on November 7th, we know that the Indonesian Hospital (in northern Gaza), and Al-Shifa Hospital and Al-Rantisi Specialized Hospital for Children (in Gaza City) have had no electricity and supplies for several weeks, while Al-Aqsa Hospital (in central Gaza), Nasser Hospital (in Khan Younis) and El-Najjar Hospital (in Rafah) are still functioning, but dialysis sessions have been shortened due to shortages of water and electricity, and patients are afraid to go to the hospitals. The message ends, “We are hoping in humanitarian intervention to try to save dialysis centres in Gaza”.

In the days that followed, Hafedh received only two more messages on the dialysis situation. A vascular surgeon from Gaza now training in Germany wrote: “This information cannot be attained these days due to the lack of communication between the dialysis centres. I tried to reach some workers in the field, but they don’t have information except that they lack supplies and electricity. The main target is to perform shorter dialysis sessions to overcome the shortages. On the other hand, people who have had a kidney transplant are now facing a great danger of rejection due to the lack of immunosuppressive medications.”

Indeed, Hafedh said, there are several hundred kidney transplant patients in Gaza, mostly from living donors. Their lives are at risk. The last message Hafedh received came from Professor Abdullah El-Kishaoui, head of the nephrology unit Al-Shifa Hospital: “The situation is so bad. We have shortages in disposables, filters and fluids for haemodialysis, immunosuppressants for kidney transplant patients. It is difficult to transfer patients out of Gaza, Rafah crossing is still closed.”

Ten days have elapsed since he received this message. More will have passed by the time this editorial is published. Our hope is that when you read this page the war will be over, and that the hospitals will have already resumed being places of healing instead of battlegrounds.

And our hope, which may be naïve, as hope usually is, but is well rooted and resilient, as hope should always be, is that colleagues like Hafedh and Alexandre will have already started to help with reconstruction, following what they both consider a commitment to the simplest and most universal duty: respecting life.