No precedents, no set protocol awaited Dr. Efrat from Gaza immediately after they arrived at who, with her staff, received young hostages freed Children’s Medical Center. There was no margin for error.
Fast Talk Ayelett Shani
Please introduce yourself.
I’m 57, the mother of four sons. I’m a pediatrician and pediatric intensive care physician, and director of Schneider Children’s Medical Center [in Petah Tikva]. Even though I have been engaged in administrative work for the past two decades of my career, I have not abandoned my profession. I love being a doctor. I love the contact with the children and the parents. It’s very important to me.
The choice of a career in pediatric intensive care is complicated in itself- certainly in Israel. But even so, I imagine that nothing prepared you for the challenge you faced in November upon release of the hostages.
Definitely not. There was also nothing that could have prepared me for it.
When did you first hear that the children being held captive in the Gaza Strip were going to be directed to your hospital?
I didn’t learn about it, I made the decision about it. On October 7, I informed the hospital’s staff that we were moving to an emergency footing and moving all of our departments into protected areas. By that evening we were already completing that process. We transferred all units, ranging from oncology to the ICU, along with all their delicate and sophisticated equipment. Hours of nonstop madness, and then, at 7 P.M., I looked around for the first time and said, “Wait a minute! Where are they? Where are the children?”
You were preparing to receive wounded children from the communities across from Gaza?
Yes. We had anticipated and prepared for that, but no children arrived. In the end, it turned out that relatively few were actually wounded [during the Hamas attacks of Oct. 7], and they were taken to Soroka [Medical Center, in Be’er Sheva]. It took me a long time to grasp that there were actually three options for the children from those communities who weren’t evacuated to hospitals. One is that they had been rescued, the second is that they had been murdered, and the third – which on that day was still hard to imagine – was that they had been taken hostage. After about a week, when the picture became clear and it turned out that there were about 30 captive children, I became totally obsessive. I started to drive the whole world crazy. I contacted everyone I knew, and many others whom I didn’t know [in the government], and told them two things: The children must be returned first. The children must come to Schneider.
Why to you? Why not to Dana-Dwek Children’s Hospital? Or to Safra, at Sheba Medical Canter?
Because we are the only stand-alone hospital for children. Here we eat and drink and speak and deal only with children. Dana-Dwek, in Ichilov Hospital [Tel Aviv], is an excellent facility; Safra [Children’s Hospital, in Ra- mat Gan] is also excellent. But a hospital director in a war situation has a million things to think about, and the vast majority of them are related to medical treatment of adults – even if the children’s hospital that’s part of their institution is serious and excellent.
Here we think only about children. Everyone who works here is child-oriented. The electrician does his work differently, in consideration of them, as do the janitor and the cook, and of course the entire medical team. And when I think about boys or girls who were in captivity, I don’t think only about the possibility that they will return wounded, or that they underwent sexual abuse, God forbid, or about the medical care they need – I think about the whole picture. About their needs, as children, from A to Z, which we are accustomed to knowing and caring for.
Look, as a physician, what is supposedly the easy part of treatment? The medical process. To heal cancer. To admit someone who’s been injured to surgery. But the other part – coping with needs and complexities – is constantly changing. It demands different thinking.
So you are saying, for example, that just as certain physicians favor separating the genders when it comes to treatment – because, they say, women’s medicine is not like men’s medicine and vice versa – children’s medical care does not resemble adult medical care.
There’s no comparison. Children are not miniature adults. Nevertheless, 95 percent of the money invested in the health system worldwide is for adult medical care, and invested not in prevention but in treatment. In my view, the pediatrician’s role is to ensure that today’s healthy children will be tomorrow’s healthy adults, and as time passes and medical technology advances, we need to have ever more predictive and preventive capabilities. The bigger the effort we make to bring pediatrics to center stage and place it under the R&D spotlight, the better it will be for all of us.
‘The teenager was tense. “Who’s that there?” he asked. I told him, “It’s a soldier, who’s guarding us, don’t worry. There’s no one else here.” “So what’s at the end, around the corner?” he asked again.’
That’s at the practical level. What about the different needs? If the medical procedure is the easy part, what is the hard part?
Understanding who the child is. How to talk to them. Are they at an age at which we can share certain things with them? Ask for their consent? We need to understand the culture, the language, the milieu – where the child comes from, who the parents are, how strong the family is. That is the basis for the entire process. With a child it’s not enough to say, “Okay, we’re going to follow the protocol for treating leukemia.”
Like in geriatrics. You care for the family, and not just the patient.
Correct. Am I addressing a mother who has read everything about the disease and feels that she can and should be a substitute for the medical staff, and I somehow have to work with this? Or, excuse the stereotype, am I addressing a family from the [Bedouin city of] Rahat, and when I explain the steps of treatment to the father, for instance, he suddenly says, “But I don’t have a refrigerator that runs on electricity, I only have a generator and it doesn’t always work, so how will we manage with medicine that needs to be refrigerated”?
What happened after you decided that the child hostages from Gaza should come to Schneider?
I sent the Health Ministry a long email, with an optimistic heading – something along the lines of “The Children Will Soon Be Back.” In it I detailed, in different sections, the infrastructure, the preparations, what needs to be learned and what needs to be taught [about treating them effectively]. It was like yallah, let’s get ready.
How can you prepare for an unprecedented event?
We scoured the medical literature and didn’t really find anything. By the way, I can tell you that I started to write an article for the New England Journal of Medicine that deals with this, and when I sent them the general proposal – about treating children who had been in captivity – the answer was “No, thanks.”
It’s not just that there is no clinical knowledge about treatment of children in captivity. There is no psychological knowledge, no historical knowledge. There is simply no knowledge.
I did find something about children in Sierra Leone who had been abducted, but it wasn’t similar to our situation. I said, “Okay, then we’ll have to invent.” We started with the infrastructure. It was clear that it couldn’t be like a hospital, but had to be more like a home. That the children would have to feel secure and protected there, and that they and their families would also need privacy as well as areas where they could wander around or sit together.
We started with a model patient room, which we built down to the last detail, including toys. The next stage was to start organizing the ward, according to the patients and the families. The child’s age. The kind of bed that would be needed. We wondered if both parents would want to sleep in, and whether there even were two parents. We built the rooms based on the structure of the family and also prepared a full-fledged plan B, in case the structure turned out to be different. We realized that we had to be flexible.
Agam Goldstein-Almog, 17, meets her grandfather Giora Goldstein, after her release (together with brothers Tal and Gal, and mother Chen). Hamas killed their father, Nadav, and sister Yam. Photos: Schneider Children \ Medical Center Spokesman’s Office
And all this without knowing at that point whether their return was even feasible.
Yes, this was a month before the negotiations over the release of the hostages even started.
Wasn’t it awful, those “ghost rooms”? To see them and know that there might not be any use for them?
It was awful. Every time we went there, we cried. Everyone who worked there cried. We got 38 teddy bears for the ward. A teddy on each bed. It just crushed your heart, each time, to see the teddy sitting on the bed and waiting. Concurrently, we also started to work on the theoretical basis of the care we would administer.
What did that include?
Mainly what not to do. Again, we knew that we would be able to handle any actual medical issues. But all the rest was unknown. When you’re not sure what to do – don’t do anything. So we said: We won’t hug, we won’t ask questions, we won’t intervene, we won’t touch. What will we do? We decided, my deputy and I, that we would observe. That we would be the ones who would physically go to the helipad and assess those arriving ourselves in order to understand their condition. We knew that we were experienced enough to understand what we would be seeing.
What were you looking for?
First of all to see that they were fully conscious. To check their complexion. Was anyone breathing in a special way, having difficulty standing or bent over? Happily, the condition of all of the children was more or less reasonable after 54 days in captivity. They were pale. Thin. But you could see that they were well enough so that we didn’t need to assist them physically. We knew we wouldn’t start immediately with blood tests and so on. They’re walking. They’re talking. Let’s leave them alone.
What about their emotional state?
There were differences that were apparent from the first minute.
Do you think that those differences stemmed from character traits or from the conditions they were held in?
Look, beyond the differences in personality, each of the hostages had a life until October 7 – that’s one chapter. The second chapter is October 7 and what they endured that day, the atrocities they experienced, the murders they witnessed. The abduction itself. In that respect, too, each of them had a distinctly different experience. The third chapter is the captivity and what they underwent there. You could see it in their eyes – yes, he seems to be okay but he’s apparently less okay than the child sitting next to him.
In contrast to the situations you cope with routinely, the story here was laid out before you in advance.
The story is a one in which some of the parts were known, which we received ahead of time and prepared for, but all the rest was not known. We didn’t actually know what happened on October 7 or what happened in captivity.
What happened in that first encounter? When they got out of the helicopter?
First of all, we asked them what they wanted. To sit on a wheelchair? To lie down on a bed? To walk? They all wanted to walk. I accompanied them with wheelchairs, in case any of them changed their mind, but no one did. There was one youth whom seemed very anxious to me. We prepared a special entrance in a hidden area, but there was a hallway in that zone which I had thought, during the preparations, might frighten them, because it looked a little like a tunnel. A long, windowless hallway, underground. So we hung Israeli flags all along it, to give them the feeling that they were home.
When I walked along there with the teenager, I saw that it wasn’t helping. He was tense. “Who’s that there?” he asked. I told him, “It’s a soldier, who’s guarding us, don’t worry. There’s no one else here.” “So what’s at the end, around the corner?” he asked again. I told him, “Nothing. Not a thing. No journalists, no photographers, no people at all. It’s a corridor for us only. No one can see us.” He wasn’t at ease, he wanted to be sure. “So for sure, for sure, for sure – there’s no one there?”
How did you feel?
It was a complicated situation. I’m supposed to be there, but also not be there. To touch, not to touch, to guide them to their room. There is really no correct or incorrect. I felt that I needed to use all my senses, as a physician, as a human being, as a mother – all together. Knowing that there was one thing I must not do: make a mistake. And at that moment, which actually repeated itself a few times, with each arrival of captives, I checked myself all the time. Maybe we made a mistake about something? Maybe, despite the meticulous planning, we missed something?
And did you miss anything? Did you come to any conclusions as you went along?
Yes. For example, when we prepared the ward, we also put clothes and shoes on the beds. For each child, according to their size. We paid less attention to colors and style because, we thought, will it really matter to anyone whether they wear red or purple? So, yes, on the first night it turned out to matter very much. So afterward we suggested that each family choose clothes from our storeroom.
What else?
We assumed that the families would want to meet the hostages as quickly as possible. Right as they came out of the elevator [into the ward]. We were so excited that no one stopped for a moment to ask whether the first encounter wouldn’t be appropriate there, in front of everyone. After the very first time I saw that the families got totally stuck in one location and that the hospital staff were standing and watching – shedding a tear because how could they not? – and that without intending to, we had infringed on the families’ privacy. So the next time I suggested that the initial encounters be held in separate rooms, meaning another 10 seconds of walking and waiting, and in fact most of the families did prefer to wait in a room.
Was there any medical justification for the families and the children to stay on, in the hospital?
No, but happily they all chose to stay, for two or three days and more.
Didn’t any of those who returned need medical treatment or supervision?
No.
In other words, they weren’t harmed physically.
None of the children who were with us underwent physical abuse. We only needed to be sure that they were eating and drinking, and that their blood tests were normal. There was a stomachache here or there, unimportant things. Normally a child in that condition would be discharged. To our delight, all the families chose to stay on, including those who said on the first day, “Thanks, but tomorrow we’ll go home.” That was a tremendous compliment for us.
So we’re actually talking about hospitalization without any medical justification per se, certainly not like in the scenarios you prepared for.
Correct.
Well, what do doctors do who don’t need to treat patients and heal them?
A lot of things. First of all, they listen. We didn’t ask things, but very quickly they started to talk. They all preferred not to leave their rooms at the start. We waited patiently. We kept the ward quiet, silent. And then it started to happen, like those cartoon characters that stick out their head, look right and left, and then beat a fast retreat. They plucked up the courage to ask for something to eat.
What did they want to eat?
Schnitzel and mashed potatoes. They arrived before dawn, slept most of the day, and that evening we were asked, “Can we have schnitzel and mashed potatoes?” It was 12:30 A.M. Of course they could have them. So the head of the kitchen and his deputy came up, in ironed uniforms, with fine dishes, not plastic, and proudly served them schnitzel and mashed potatoes. We were a bit worried about refeeding syndrome [problems that can crop up following excessive or sudden ingestion of food after a period of starvation]. We spoke a lot with the dietitian about what and how they would eat when they got here. But when they arrived, we understood that it wasn’t applicable.
‘They said they were hungry. All of them. All the time. And in the same breath, they added, “But the captors didn’t have anything to eat either. It wasn’t that they were starving us, but just that they didn’t have food either.’”
Go tell a kid who wants pizza or schnitzel, “No, have a hardboiled egg and white cheese now.” There was one girl who wanted snack food and wouldn’t touch anything else. So, for three or four days, all she ate was snacks. We didn’t interfere. We observed the process they were undergoing, which lasted a few days and started from a point where there was zero choice in life – where the patients hadn’t been able to talk, laugh, cry, look out the window or express an opinion.
During those days, things simply evolved slowly. It may have taken a moment for them to come out of their room. We’d ask, “Maybe you feel like seeing where you can paint? There’s a painting corner at the end of the hall.” And I’d walk with the patient very slowly, but she wouldn’t agree to go without Mom. So Mom would come too. And the next day, on the second try, she would agree to come alone. It was a matter of getting used to a situation in which the child is very protected on the one hand, but that on the other hand makes normality possible.
You created a transitional space.
Yes, a pleasant transitional space, warm, lots of fun, but which also allows for moments of difficulty or break down. Where there’s always someone to talk to, but the clear message is that if you don’t want to talk with them, you don’t have to. And when other elements entered the picture – the army, the Shin Bet security service, the Institute of Forensic Medicine – it was all done gently and with great sensitivity.
Meaning what?
These people didn’t enter at all until they got authorization from our psychosocial and medical teams. The whole process was implemented with tremendous sensitivity. The amazing thing was that the children themselves wanted to talk [about their captivity], because they un derstood that talking could be very meaningful in terms of the other hostages being held.
Was the time it took for the patients to make contact related to differences in the conditions of their captivity?
The conditions of captivity kept changing all the time, because most of them were moved from place to place. One of the mothers told us, for example, that at first they stayed with a family [in Gaza]. The family treated them well, gave them the run of the house, shared food with them. But then they were moved to a different location, where their captors didn’t allow them to get up or to talk. They told them that Israel didn’t exist anymore – that there was nowhere for them to go back to.
This mother told me that one night they were taken out of their hiding place in order to be moved to a different site, and then she saw the devastation around her for the first time. Those poor unfortunate people, she thought to herself. I was stunned. I looked at her and said, “Wow! You’re walking through the rubble as a hostage with your children after such a severe trauma, after you lost relatives, you don’t know whether you will live or die, and you still have enough empathy to think they are unfortunates. That’s outstanding.”
What else did they say?
That they were hungry. All of them. All the time. And in the same breath, they added, “But the captors didn’t have anything to eat either. It wasn’t that they were starving us, but just that they didn’t have food either.” The hostages were very, very frightened. Every single moment.
Did they really believe they had no place to return to? That no one was waiting for them at home?
Some of them did. A few had managed to hear fragments of news. There was that wonderful grandmother who had been able to listen to a transistor radio [while in captivity]. Others’ information came from the captors, who told them they would be there forever and that they [the captors] were more worried about them than Israel was, and the proof was that Israel was bombing “and will kill all of us. If they really cared about you, they wouldn’t bomb Gaza.”
In the end, after all this, we didn’t even talk about “doing medicine.”
It seems like that, but we did. Just this morning we heard a talk by a young resident about hope in medicine and its significance. There are quite a few articles and studies on this subject, and I believe that giving people hope is part of medicine. It’s part of what we do when caring for children hospitalized for routine things, along with the administering of actual treatment – but in different proportions. Normally it’s 50-50, and with the returned hostages it was more like 90-10. That’s part of our job, as people engaged in this profession.
It’s not a matter of psychologists or art therapists. But, say, to bring a hairstylist into the ward and say nothing, only to wait and see – maybe one of the returning mothers will want a haircut or to have her hair done? And to see, afterward, that she feels better about herself. That too is medicine. So, yes, a manicure and a hairdo are also sometimes medicine.
What was the hardest moment for you?
It was on the day the cease-fire ended. There was an air-raid siren, and what was on my mind was one of the released women whose husband remained in captivity. I got up and drove to the hospital. She was just coming toward me in the corridor. “That’s it, he’ll stay there, he’ll die there,” she said.
And, apropos medicine and hope, I replied, “Listen, I want to reveal something to you. I want to tell you how all this looks from my point of view. You got here three days ago. Until we saw you actually standing here, we felt what you are feeling now: A war is going on, the hostages won’t survive, they won’t make it. Yet here you are. You survived 52 days under terrible bombing attacks; you know that it’s possible to survive. You know better than me that it’s possible.” That’s the thing with hope, it must exist. It’s what gives us strength.
Yoni Asher reunited with his wife, Doron Katz-Asher, 34, and daughters Raz, 5, and Aviv, 2, at the hospital. “We kept the ward quiet, silent,” Bron-Harlev says. “And then it started to happen. They plucked up the courage to ask for something to eat.”