LIVE UPDATES: Israeli weapons with shrapnel designed to maximise casualties, doctors say

Surgeons volunteering in Gaza have reported catastrophic injuries among children caused by Israeli-made weapons designed to maximise shrapnel dispersion, resulting in severe casualties, according to The Guardian on Thursday.

July 2, 2024 at 8:40 am

A Palestinian child receives medical treatment at Al Ahli Baptist Hospital after getting severely injured in an Israeli attack over Rimal neighborhood in Gaza City, Gaza on July 07, 2024. [Dawoud Abo Alkas – Anadolu Agency]

Surgeons who worked in European and al-Aqsa hospitals describe extensive wounds caused by ‘fragmentation’ shrapnel experts say is designed to maximize casualties

Israeli-made weapons designed to spray high levels of shrapnel are causing horrific injuries to civilians in Gaza and disproportionately harming children, foreign surgeons who worked in the territory in recent months have told the Guardian.

The doctors say many of the deaths, amputations and life changing wounds to children they have treated came from the firing of missiles and shells – in areas crowded with civilians – packed with additional metal designed to fragment into tiny pieces of shrapnel.

Volunteer doctors at two Gaza hospitals said that a majority of their operations were on children hit by small pieces of shrapnel that leave barely discernible entry wounds but create extensive destruction inside the body. Amnesty International has said that the weapons appear designed to maximise casualties.

Feroze Sidhwa, a trauma surgeon from California, worked at the European hospital in southern Gaza in April.

“About half of the injuries I took care of were in young kids. We saw a lot of so-called splinter injuries that were very, very small to the point that you easily missed them while examining a patient. Much, much smaller than anything I’ve seen before but they caused tremendous damage on the inside,” he said.

Weapons experts said the shrapnel and wounds are consistent with Israeli-made weapons designed to create large numbers of casualties unlike more conventional weapons used to destroy buildings. The experts question why they are being fired into areas packed with civilians.

an x-ray showing damage from fragmentation shrapnel
X-ray of the damage done to a 15-year-old’s leg by fragmentation shrapnel, some of which is still lodged in the bone. The surgeon said: “The shrapnel entered from the left into the tibia bone and exited through the fibula to the right of the image. Our word for very smashed bone is ‘comminuted’. Bone comminution does not get greater than this.” The surgeon has put in a stainless steel plate screwed into the tibia. Photograph: The Guardian

The Guardian spoke to six foreign doctors who have worked at two hospitals in Gaza, the European and al-Aqsa, in the last three months. All of them described encountering extensive wounds caused by “fragmentation” weapons, which they said have contributed to alarming rates of amputations since the war began. They said the injuries were seen in adults and children but that the damage done was likely to be more severe to younger bodies.

“Children are more vulnerable to any penetrating injury because they have smaller bodies. Their vital parts are smaller and easier to disrupt. When children have lacerated blood vessels, their blood vessels are already so small it’s very hard to put them back together. The artery that feeds the leg, the femoral artery, is only the thickness of a noodle in a small child. It’s very, very small. So repairing it and keeping the kid’s limb attached to them is very difficult,” Sidhwa said.

Mark Perlmutter, an orthopaedic surgeon from North Carolina, worked at the same hospital as Sidhwa.

“By far the most common wounds are one or two millimetre entry and exit wounds,” he said.

“X-rays showed demolished bones with a pinhole wound on one side, a pinhole on the other, and a bone that looks like a tractor trailer drove over it. The children we operated on, most of them had these small entrance and exit points.”

Perlmutter said children hit by multiple pieces of tiny shards often died and many of those who survived lost limbs.

“Most of the kids that survived had neurologic injuries and vascular injuries, a major cause of amputation. The blood vessels or the nerves get hit, and they come in a day later and the leg is dead or the arm is dead,” he said.

Sanjay Adusumilli⁩, an Australian surgeon who worked at the al-Aqsa hospital in central Gaza in April, recovered shrapnel made up of small metal cubes about three millimetres wide while operating on a young boy. He described wounds from fragmentation weapons distinguished by the shards of shrapnel destroying bone and organs while leaving just a scratch on the skin.

Explosives experts who reviewed pictures of the shrapnel and the doctors’ descriptions of the wounds said they were consistent with bombs and shells fitted with a “fragmentation sleeve” around the explosive warhead in order to maximise casualties. Their use has also been documented in past Israeli offensives in Gaza.

Trevor Ball, a former US army explosive ordnance disposal technician, said the explosive sprays out tungsten cubes and ball bearings that are far more lethal than the blast itself.

“These balls and cubes are the main fragmentation effect from these munitions, with the munition casing providing a much smaller portion of the fragmentation effect. Most traditional artillery rounds and bombs rely on the munition casing itself rather than added fragmentation liners,” he said.

Cubes removed from a child by Sanjay Adusumilli, an Australian surgeon working at the al-Aqsa hospital in central Gaza.
Cubes removed from a child by Sanjay Adusumilli, an Australian surgeon working at the al-Aqsa hospital in central Gaza. Photograph: Obtained by The Guardian

Ball said the metal cubes recovered by Adusumilli are typically found in Israeli-made weapons such as certain types of Spike missiles fired from drones. He said the doctors’ accounts of tiny entry wounds are also consistent with glide bombs and tank rounds fitted with fragmentation sleeves such as the M329 APAM shell, which is designed to penetrate buildings, and the M339 round which its manufacturer, Elbit Systems of Haifa, describes as “highly lethal against dismounted infantry”.

Some of the weapons are designed to penetrate buildings and kill everyone within the walls. But when they are dropped onto streets or among tents, there is no such containment.

“The issue comes with how these small munitions are being employed,” said Ball. “Even a relatively small munition employed in a crowded space, especially a space with little to no protection against fragmentation, such as a refugee camp with tents, can lead to significant deaths and injuries.”

Amnesty International first identified ammunition packed with the metal cubes used in Spike missiles in Gaza in 2009.

“They appear designed to cause maximum injury and, in some respects, seem to be a more sophisticated version of the ball-bearings or nails and bolts which armed groups often pack into crude rockets and suicide bombs,” Amnesty said in a report at the time.

Ball said that weapons fitted with fragmentation sleeves are “relatively small munitions” compared with the bombs that have a wide blast area and have damaged or destroyed more than half the buildings in Gaza. But because they are packed with additional metal, they are very deadly in the immediate vicinity. The shrapnel from a Spike missile typically kills and severely wounds over a 20-metre (65-ft) radius.

Another weapons expert, who declined to be named because he sometimes works for the US government, questioned the use of such weapons in areas of Gaza crowded with civilians.

“The claim is that these weapons are more precise and limit casualties to a smaller area. But when they are fired into areas with high concentrations of civilians living in the open with nowhere to shelter, the military knows that most of the casualties will be those civilians,” he said.

In response to questions about the use of fragmentation weapons in areas with concentrations of civilians, the Israel Defense Forces said that military commanders are required “to consider the various means of warfare that are equally capable of achieving a defined military objective, and to choose the means that is expected to cause the least incidental damage under the circumstances.

“The IDF makes various efforts to reduce harm to civilians to the extent feasible in the operational circumstances ruling at the time of the strike,” it said.

“The IDF reviews targets before strikes and chooses the proper munition in accordance with operational and humanitarian considerations, taking into account an assessment of the relevant structural and geographical features of the target, the target’s environment, possible effects on nearby civilians, critical infrastructure in the vicinity, and more.”

The UN children’s agency, Unicef has said that “staggering” numbers of children have been wounded in Israel’s assault on Gaza. The United Nations estimates that Israel has killed more than 38,000 people in Gaza in the present war of which at least 8,000 are confirmed to be children, although the actual figure is likely to be much higher. Tens of thousands have been wounded.

In June, the UN added Israel to a list of states committing violations against children during conflict, describing the scale of killing in Gaza as “an unprecedented scale and intensity of grave violations against children”, principally by Israeli forces.

Many of the cases recalled by the surgeons involved children severely injured when missiles landed in or near areas where hundreds of thousands of Palestinians are living in tents after being driven from their homes by the Israeli assault.

an x-ray shows shrapnel lodged in a body
An X-ray of a man with tiny pieces of shrapnel (the white specks) in his body. Photograph: The Guardian

Perlmutter described repeatedly encountering similar wounds.

“Most of our patients were under 16,” he said. “The exit wound is only a couple millimetres big. The entrance wound is that big or smaller. But you can see it is extremely high velocity because of the damage it does on the inside. When you have multiple small fragments travelling at insane speeds, it does soft tissue damage that far outweighs the size of the fragment.”

Adusumilli⁩ described treating a six-year-old boy who arrived at the hospital after an Israeli missile strike close to the tent where his family was living after fleeing their home under Israeli bombardment. The surgeon said the child had pinhole wounds that gave no indication of the scale of the damage beneath the skin.

“I had to open his abdomen and chest. He had lacerations to his lung, to his heart, and holes throughout his intestine. We had to repair everything. He was lucky that there was a bed in the intensive care unit. But, despite that, that young boy died two days later,” he said.

An American emergency room doctor now working in central Gaza, who did not want to be named for fear of jeopardising his work there, said that medics continue to treat deeply penetrating wounds created by fragmentation shards. The doctor said he had just worked on a child who suffered wounds to his heart and major blood vessels, and a build up of blood between his ribs and lungs that made it difficult to breathe.

Sidhwa said that “about half of the patients that we took care of were children”. He kept notes on several, including a nine year-old girl, Jouri, who was severely injured by shards of shrapnel in an air strike on Rafah.

“We found Jouri dying of sepsis in a corner. We took her to the operating room and found that both of her buttocks had been completely flayed open. The lowest bone in her pelvis was actually exposed to the skin. These wounds were covered in maggots. Her left leg she was missing a big chunk of the the muscles on the front and back of the leg, and then about two inches of her femur. The bone in the leg was just gone,” he said.

Sidhwa said doctors were able to save Jouri’s life and treat septic shock. But in order to save what remained of her leg, the surgeons shortened it during repeated operations.

The problem, said Sidhwa, is that Jouri will need constant care for years to come and she’s unlikely to find it in Gaza.

“She needs advanced surgical intervention every one to two years years as she grows to bring her left femur back to the length it needs to be to match her right leg, otherwise walking will be impossible,” he said.

“If she does not get out of Gaza, if she survives at all, she will be permanently and completely crippled.”

Adusumilli⁩ said fragmentation weapons resulted in high numbers of amputations among children who survived.

“It was unbelievable the number of amputations we had to do, especially on children, he said. “The option you’ve got to save their life is to amputate their leg or their hands or their arms. It was a constant flow of amputations every day.”

Adusumilli operated on a seven year-old girl who was hit by shrapnel from a missile that landed near her family’s tent.

A 15-year-old malnourished boy with a pinhole wound in the middle of his chest.
A 15-year-old malnourished boy with a pinhole wound in the middle of his chest. Photograph: The Guardian

“She came in with her left arm completely blown off. Her family brought the arm in wrapped in a towel and in a bag. She had shrapnel injuries to her abdomen so I had to open up her abdomen and control the bleeding. She ended up having her left arm amputated,” he said.

“She survived but the reason I remember her is because as I was rushing into the operating theatre, she reminded me of my own daughter and it sort of it was very difficult to accept emotionally.”

Unicef estimated that in the first 10 weeks of the conflict alone about 1,000 children lost one or both of their legs to amputations.

The doctors said that many of the limbs could be saved in more normal circumstances but that shortages of medicines and operating theatres limited surgeons to carrying out emergency procedures to save lives. Some children endured amputations without anaesthetic or painkillers afterwards which hindered their recovery alongside the challenges of rampant infections because of unsanitary conditions and lack of antibiotics.

Adusumilli said that, as a result, some children saved on the operating table died later when they could have been saved in different conditions.

“The sad part is that you do what you can to try and help these kids. But at the end of the day, the fact that the hospital is so overcrowded and doesn’t have the resources in intensive care, they just end up dying later on.”

articolo pubblicato BMJ. english -italian


December 3, 2023

Dear  Editor, 

you aptly illustrated that UN bodies asked for full stop of the military operations on Gaza, appealed to the ICC, in view of a carnage of women and children (70% of the 15.000 plus victims) as never before in the century and targeting of health infrastructures and personnel. 

After a pause, this is just starting again.

Calls to protect health personnel by medical professionals, were not echoed by the Israeli Medical Association, national medical associations, and the World Medical Association; they remained silent, regardless of clear targeting of health services. They ignored the sacrifice in lives (plus 160 victims) of medical teams and expressed no solidarity and support for their abnegation in the dire situation. 

The ethical dilemmas of Gaza professionals lacking means for proper anesthesia, pain relief and for reducing post trauma infections, should interrogate medical professionals and be ground for requesting protection and accounting. Hundreds more children’s and adult’s lives were lost in hospitals, adding to those killed by the weapons. 

It was not proven that Al Shifa was the location of central command of Hamas, and anyhow how this implies attacks on all (29/35) health facilities in the North of Gaza? 

Since October 8, all were strangled by cutting water, electricity, fuel, food and all medical supplies, menaced if did not close, then directly hit and personnel arrested or displaced forcibly out of the facility. 

Summarizing major events: October  17 Alhi hospital courtyard bombed; Turkish friendship cancer, Eyes, Wada, Pediatric Nasser and Rantissi hospitals hit and forced to close, the last with forcible displacement of the personnel and families, while not transportable babies were left unattended; Awda hospital and the Aqsa hospital repeatedly damaged by hits, whit many victims; Indonesia hospital and Shifa -both hit many times destroying whole sections, killing attending nurses and others. Essential machinery, surgical theaters, oxygen generator, solar panels, and ICUs directly hit; personnel kept captive while bodies of the dead accumulated in their premises, when hospital had become shelter for thousands of displaced people. 

Regardless of abnegation of personnel, no fully functional medical facilities and maternities remain in the North of Gaza. 52 out of 75 primary care clinics and adult not communicable disease and dialysis services forced to close. The medical and science faculties in Gaza were destroyed.  More than 100 UNWRA personnel was killed. More than 50 ambulances taken off use.

Worse, this is not totally new or unexpected: since 2014 IDF attacked hospitals and education structures, impairing survival and future for all. During the 17 years siege of Gaza, health services were constantly impaired through denial of instruments and supplies, restricting permits for training and of access for foreign professionals, as documented by UN, major NGOs (1). Since 2021 this ban was the tightest, and the economic crisis due to the blockade induced decrease in the number of university medicine and science students.

The temporary ceasefire showed the immense devastation also of hospitals, made more sad because attacks on hospital was recommended also by 100 Israeli doctors (2) in contravention with any international law and ethics.

Should not all professionals and their associations, finally chorally ask a full unconditional and long lasting ceasefire, condemn the destruction of health structure which multiplies deaths, recognize the abnegation of the Gaza colleagues, appreciate that a war crime has been committed and lament also the forced dispersal of accumulated work, experience and labor invested in the Gaza’s health system which can hardly be reconstructed in short time? should they not uphold the inalienable human right of care for the people of Gaza? should they not help by standing strongly to go beyond temporary charity and advocate for stable resolutions?

Paola Manduca, Geneticist, 

retired Associate Professor University of Genoa, Italy


Caro editore,

hai giustamente illustrato che gli organismi delle Nazioni Unite hanno chiesto la cessazione totale delle operazioni militari su Gaza, hanno fatto appello alla Corte penale internazionale, in vista di una carneficina di donne e bambini (il 70% delle oltre 15.000 vittime) come mai prima nel secolo e che ha preso di mira la salute infrastrutture e personale.

Dopo una pausa, tutto questo ricomincia.

Le richieste di protezione del personale sanitario da parte dei professionisti medici non hanno trovato eco nell’Associazione medica israeliana, nelle associazioni mediche nazionali e nella World Medical Association; sono rimasti in silenzio, nonostante la chiara presa di mira dei servizi sanitari. Hanno ignorato il sacrificio di vite umane (più di 160 vittime) delle équipe mediche e non hanno espresso solidarietà né sostegno per la loro abnegazione in una situazione disastrosa.

I dilemmi etici dei professionisti di Gaza, privi di mezzi per un’anestesia adeguata, per alleviare il dolore e per ridurre le infezioni post trauma, dovrebbero interrogare i professionisti medici e costituire la base per richiedere protezione e rendicontazione. Altre centinaia di bambini e adulti hanno perso la vita negli ospedali, aggiungendosi a quelli uccisi dalle armi.

Non è stato dimostrato che Al Shifa fosse la sede del comando centrale di Hamas, e comunque come ciò implica attacchi a tutte le (29/35) strutture sanitarie nel nord di Gaza?

Dall’8 ottobre, tutti sono stati strangolati tagliando acqua, elettricità, carburante, cibo e tutte le forniture mediche, minacciati se non venivano chiusi, poi colpiti direttamente e il personale arrestato o sfollato con la forza fuori dalla struttura.

Riassumendo i principali eventi: 17 ottobre bombardato il cortile dell’ospedale Alhi; Amici turchi per cancro, gli ospedali Eyes, Wada, Pediatric Nasser e Rantissi colpiti e costretti a chiudere, l’ultimo con sfollamento forzato del personale e delle famiglie, mentre i bambini non trasportabili sono stati lasciati incustoditi; l’ospedale di Awda e l’ospedale di Aqsa ripetutamente danneggiati dai colpi, con numerose vittime; L’ospedale indonesiano e quello di Shifa hanno entrambi colpito più volte distruggendo intere sezioni, uccidendo infermieri e altre persone. Colpiti direttamente macchinari essenziali, sale operatorie, generatori di ossigeno, pannelli solari e unità di terapia intensiva; il personale veniva tenuto prigioniero mentre i corpi dei morti si accumulavano nei loro locali, quando l’ospedale era diventato rifugio per migliaia di sfollati.

Nonostante l’abnegazione del personale, nel nord di Gaza non rimangono strutture mediche e maternità pienamente funzionanti. 52 su 75 ambulatori di assistenza primaria e servizi di dialisi e malattie non trasmissibili per adulti sono costretti a chiudere. Le facoltà di medicina e di scienze a Gaza sono state distrutte. Più di 100 membri del personale dell’UNWRA furono uccisi. Sono state dismesse più di 50 ambulanze.

Quel che è peggio, non è una cosa del tutto nuova o inaspettata: dal 2014 l’IDF ha attaccato ospedali e strutture educative, compromettendo la sopravvivenza e il futuro di tutti. Durante i 17 anni di assedio di Gaza, i servizi sanitari sono stati costantemente compromessi attraverso la negazione di strumenti e forniture, la limitazione dei permessi di formazione e di accesso per i professionisti stranieri, come documentato dalle Nazioni Unite e dalle principali ONG (1). Dal 2021 questo divieto è stato il più severo e la crisi economica dovuta al blocco ha provocato una diminuzione del numero degli studenti universitari di medicina e scienze.

Il cessate il fuoco temporaneo ha mostrato l’immensa devastazione anche degli ospedali, resa ancora più triste perché gli attacchi agli ospedali sono stati raccomandati anche da 100 medici israeliani (2) in violazione di qualsiasi diritto ed etica internazionale.

Non dovrebbero tutti i professionisti e le loro associazioni chiedere finalmente in coro un cessate il fuoco totale, incondizionato e duraturo, condannare la distruzione delle strutture sanitarie che moltiplica le morti, riconoscere l’abnegazione dei colleghi di Gaza, apprezzare che è stato commesso un crimine di guerra e lamentare anche la forzata dispersione del lavoro accumulato, dell’esperienza e della manodopera investita nel sistema sanitario di Gaza che difficilmente può essere ricostruito in breve tempo? non dovrebbero forse sostenere il diritto umano inalienabile alla cura del popolo di Gaza? non dovrebbero forse aiutarli impegnandosi con forza ad andare oltre la carità temporanea e a sostenere risoluzioni stabili?

Paola Manduca, Geneticist, 

retired Associate Professor University of Genoa, Italy







The war we don’t see: metals and deformities

Marwa and Hameed have only one child who is still alive. In 2012, a little girl died in Marwa’s life – with a deformed head, without a brain. In 2013, Leyla was born, but she died half an hour after birth – without kidneys, with deformed arms. The neighbours, Nadia and Mohammad, had three children, but all three died shortly after birth. The fourth child was born in 2011, dead and deformed. We are in Fallujah, an old city with 300,000 inhabitants. Fallujah – the Mother of Mosques – was the base of the Iraqi resistance, and was slaughtered by the US Army in 2004. Twice, in April and in November, everything alive in Fallujah was the target of killers on rooftops and in cockpits. Two years later, more and more mothers in the city started to have abortions, and more and more children were born deformed. Just like in Basra in the South: the bombing of Basra began in the Gulf War in 1990 and continued for twenty years. In 1995, more abortions and malformations was observed. In 2013, the number tripled. As in Nangarhar, the province that took the most bombs during America’s revenge war against Afghanistan after the 11 September attack. In 2005, I (HH) was invited by colleagues at the provincial hospital in Jalalabad to study birth defects they had never seen before.

Is there a pattern here? Let’s look at Gaza: In Christmas 2008, Gaza was bombed day and night for three weeks. Local wars are opportune laboratories for testing “improved weapons”, and two months earlier Israel had received batches of new American high explosives. In the tissue samples from the wounds of the survivors of the Christmas War, our research team found aluminium, copper, mercury, barium, vanadium, nickel, manganese and cadmium – all metals in higher concentrations than in uninjured control subjects. In 2011, we analyzed hair samples from newborns with birth defects at Shifa hospital. The concentration of mercury and selenium was significantly higher in the deformed babies than in healthy controls. In hair samples from pregnant Gazan mothers after the 2014 war, we observed the same pattern. From 2006 to 2017, the frequency of congenital structural malformations has increased from 1.1 to 1.9% and preterm births from 1.1 to 7.9%. About 40% of these children will die during the first month of life. But it’s worse: Malformations of the heart are not included – add two percent. Diseases and system errors making their clinical debut later in life such as cancer, immune defects and behavioral disorders are not included – add at least five percent.

Epigenetics and metals

Our body is in constant change. From the time I attach myself to the wall of the warm womb until I die, I form new cells and discharge cells that are damaged or expired. New cells are created on the basis of the gene recipes stored in the previous generation. This is the river of life. It can be damaged in two ways. Either genetically – by messing with the recipe, the DNA molecule in the cell nucleus. Or epigenetically – by messing up the expression, transmission and understanding of the recipes, of the gene signals. Because cells are talking to each other, and they use estrogen channels for communication, both in girls and boys. A number of metals can interfere with the recipient cells’ estrogen receptors, thus creating incorrect signals into the cell nucleus. These false messengers – “metal estrogens” – do not work along a simple dose-response line, the more-brandy-the-more-drunk. Minimal quantities are enough to confuse the signaling system and thereby cell division, and the effects of the heavy metal cocktail are totally unpredictable. In the first weeks of life in the mother’s womb, while we are just a cluster of a few hundred stem cells, while the organs – and especially the nervous tissue – are in the making, a single reading error may trigger disaster.

Let’s trace the path to these metals: Thermobaric projectiles are used against apartment buildings and shelters/tunnels. Thermo(heat)-bar(pressure) explosives work by spreading a cloud of highly explosive gases which are then ignited in an ultra-fast explosion. No conventional explosive weapon creates equivalent heat and pressure. The latest generation thermobaric projectile uses aluminum dust as explosive gas. Microparticles of aluminum – 5 hundredths of a millimeter in size – with a coating of heavy metal are ignited and spread over the impact field. Colleague Ghassan Abusitta at Shifa hospital reported three weeks ago more and more burn patients, then the thermobaric weapon are in use.

The explosive dust spreads everywhere. The pulverization of buildings spreads the metals to the entire population. Mum breathes, drinks and eats – and is slowly poisoned. The metals pass from the mother’s blood, across the placental barrier and into the fetus’s blood, where they also cross the blood-brain barrier. Mother dilutes her own toxic reserves while poisoning her young. All the metals we found in the tissue samples in Gaza have documented epigenetic effects. If this is not chemical warfare, the authors of this chronicle have misunderstood the term.

The hardest thing to think about

Cells talk to each other, but they have memory as well: Nano-doses of heavy metals leave epigenetic traces in the fetal germ cells. These traces lie dormant, are activated during adolescence, and can then be passed on to grandchildren’s children.

What kind of future are we looking into?

Hans Husum is a surgeon with a doctorate in war surgery.

Paola Manduca is professor of genetics at the University of Genoa.

“Klassekampen”, December 1, 2023