Dr Mohammed Harara, 28, had barely begun working as a general practitioner when he was thrust to the front lines of a warzone, forced to become a jack-of-all-trades.
In the nearly eight months since Israel launched its offensive on Gaza, Harara has seen more than he thought he ever would.
Like the maggot-infested wounds of the maimed that he has had to stand by and helplessly look at.
Lacking medication and even basic hygiene materials, Harara and his colleagues are not able to clean – or keep clean – festering wounds.
Also complicating their struggles are the patients’ severely compromised physical conditions, which are slow to heal and can make such an infestation lethal.
“Slowly, these unhygienic conditions caused the body to go into sepsis and people were dying,” he told Al Jazeera.
The displaced, the wounded, the frail
Experts say growing rates of malnourishment are compromising the health of a people battered by Israel’s war, preventing them from ever fully recovering.
British vascular surgeon Mahim Qureshi could tell that the Palestinians she treated during her two weeks of volunteering in Gaza were severely undernourished.
As she and her colleagues from British charity Medical Aid for Palestinians entered the besieged territory from Egypt, through the Rafah crossing, Qureshi remembers a welcoming atmosphere.
An “I love Gaza” sign greeted the team and the April weather was “perfect”, she recounts.
“I remember staring at that [sign], realising just how privileged I was to have been able to come to Gaza,” Qureshi told Al Jazeera.
But as they rolled out on the crossing’s other side, the devastation of Israel’s assault was everywhere, she said.
On the drive to Deir el-Balah, in central Gaza, the surgeon saw thousands and thousands of displaced Palestinians, many of whom were very frail and thin.
Once they arrived at Al-Aqsa Martyrs Hospital, Qureshi saw hundreds more frail, wounded displaced Palestinians crowded in every available space – in the reception area, on every floor, in the stairwells.
She was particularly pained to see children whose clothes were hanging off their small frames, the opposite of a healthy child steadily outgrowing their clothes, she said.
Over the coming days, she would see dozens of patients who, due to starvation, had worsening health conditions.
“People that would have had very treatable or curable conditions several months ago, are presenting with very advanced disease,” said Qureshi.
For these individuals, their immunity and their ability to heal were reduced, she added.
“The ability for cells to divide in the absence of vital nutrients that come from fresh food – and they have had no intake of such fresh foods for such a long period of time – [makes it] extremely difficult for the mind and the body to recover and regenerate,” Qureshi said.
Before the war, Palestinians in Gaza were already suffering from micronutrient deficiencies, largely due to the Israeli blockade, according to Amber Alayyan.
But since October 7, rates of acute malnutrition are rising rapidly, the malnutrition expert, paediatrician and deputy manager for Doctors Without Borders (Medecins Sans Frontieres, or MSF) in Palestine, said.
Micronutrient deficiency is the term used to describe a lack of essential vitamins and minerals that our bodies need to function. But acute malnutrition is a larger issue, which leads to the wasting away of one’s fat and muscle stores, Alayyan said.
“When you’re starting to worry about a population that doesn’t have any access to food, that’s when you start screening for malnutrition,” she told Al Jazeera.
But the war has rendered even screening impossible. Due to destroyed hospitals and medical labs, doctors from MSF and other aid organisations are unable to run blood tests to confirm malnutrition among Palestinians in Gaza as they normally would, Alayyan said.
Instead, they are making diagnoses based on clinical symptoms, she said.
Among the symptoms are fatigue, complications from injuries including the development of chronic diseases, complications in pregnancy, and poor healing of wounds and burns, the doctor said.
The inability to heal from injuries is also deepened by poor hygiene and infection control, Alayyan said, conditions that her team, and doctors like Harara and Qureshi, have seen firsthand in Gaza.
“You’re more at risk of getting infections when your body is not well-nourished … tissues need to be healthy and effectively well-fed to be able to close over a wound,” she explained.
Both Alayyan and Qureshi likened a malnourished body to one suffering from anorexia nervosa, clarifying that the latter is a condition with a large psychological component.
Still, while malnutrition starts as physical deterioration, Harara has witnessed how devastating the effects of malnutrition can be on the psyche of the people he has been treating.
“The mental and emotional state of realising what’s happening to you is most exhausting,” he said, explaining that the body starts to feed on itself, slowly shutting down.
“Nobody will understand the extent of this damage unless they live through it.”
Improvisation in the time of war
Alayyan said that while malnutrition is a common, unfortunate component of war, with food often used as a weapon in conflict, its presence is particularly egregious in Gaza.
Sudan is experiencing higher rates of malnutrition than Gaza due to the continuing war there, but the rate at which malnutrition has grown in the besieged enclave over the last seven months is alarming, she said.
Accessing those in need is also uniquely difficult in Gaza when compared with other places where malnutrition is present, such as the Central African Republic, or Nigeria, said Alayyan.
“When your teams are afraid of being themselves attacked, bombed, shot … it makes it very difficult for them to circulate among the population,” she explained.
“It means that you have very small sample sizes because the only samples of people you’re getting are the people who are coming to your health clinic. So you can’t assess the population’s malnutrition status because you’re not seeing the whole population. We cannot get, for example, get to the north – no one can safely get to the north,” she added.
Despite these hurdles, and the inability to develop customised treatment plans, MSF and other organisations are still trying to combat malnutrition among the population they do have access to through nutritional supplements.
Qureshi also learned how to make adjustments in her practice due to the war conditions.
At Al-Aqsa, she operated in a former maternity unit without the “basic equipment that has been present in vascular surgical theatres” for decades, she said.
The rooms had inadequate lighting and no water, there was limited ability to maintain surgical sterility, and they had to fashion surgical drapes out of hospital gowns.
“We had to improvise, we had to innovate, and we had to do the very best we could with what we had available,” said Qureshi.
Harara, who has been working day in and day out since October 7, knows full well that many of his dying patients could have been saved if there had been supplies available.
The aspiring plastic surgeon, who has now treated patients with all types of ailments, wishes he had a superpower to save them all.
“I’ve had the honour to serve my people, but at the same time I’m drained. I’ve been living in hospitals for the last seven months. It’s only so much a person can handle,” he said.
“I wish the world was able to stop this from happening before we become history lessons.”
