at first glance, the Sami Ofer Fortified Emergency Hospital looks like any other parking lot, albeit with beautiful floors... (Photo: courtesy Qanta Ahmed)

At first glance, the Sami Ofer Fortified Emergency Hospital looks like any other parking lot, albeit with beautiful floors… (Photo: courtesy Qanta Ahmed)

“A hospital is only a building until you hear the slate hooves of dreams galloping upon its roof. You listen then and know that here is no mere pile of stone and precisely cut timber but an inner space full of pain and relief. Such a place invites mankind to heroism.”

Richard Selzer, Taking the World in for Repairs, 1987

I am again in Haifa, here to explore Israel’s extraordinary Sammy Ofer Fortified Emergency Hospital at Rambam Medical Center- the world’s largest subterranean hospital. I had heard about it during my first visit to the Rambam Medical Center as part of my tour of The Technion’s medical campus last spring, but at the time it was still under construction and it would be almost a full year before I would get to visit it.

Rambam Medical Center is the referring center for twelve district hospitals, as well as the United Nations Forces stationed in the region, the Israeli Defense Forces of the Northern Front and the United States’ Sixth Fleet. It provides what’s known as quaternary level care — advanced levels of highly specialized medicine not widely available. Partly because of location and largely because of expertise, Rambam Medical Center is the largest and most experienced trauma receiving hospital in the whole of Israel. In a battleworn country intimately familiar with trauma, mastery in trauma is a hard-won and hotly contested accolade indeed. Rambam Medical Center’s abilities are measured the way medicine is always judged, by the stark mathematics of survivorship. More victims of trauma survive when treated here than anywhere else in the nation.

Last May, at Rambam Medical Center, I had entered the emergency room through triple sets of steel doors, which were used to seal off the Emergency Room from conventional warfare. This was the emergency room that had functioned full force despite the onslaught of Hezbollah missiles raining onto Haifa during the 2006 Israel Lebanon War.

“We could feel the missiles landing in the Mediterranean…our Emergency room would shake with their impact, but inside we kept treating the patients,” one person explained. I could almost imagine the impact against the hive encompassing acute trauma.

During the Israel Lebanon War, Haifa was under active fire for 34 days. More than sixty rockets struck within a half-mile radius of the hospital alone. The hospital received 792 casualties in that month of war, of whom 254 were soldiers. But life in Haifa, like the rest of Israel. doesn’t stop because of war. Rambam Medical Center still delivered 247 babies, handled 1587 surgeries, received 2000 admissions, dealt with 7000 emergency room visits and conducted 28000 outpatient appointments while managing the fallout of full on battle.

Colleagues in the Emergency Room showed me around the same receiving bay where the Turkish flotilla protestors and IDF soldiers were treated after the Flotilla Incident in 2010. Heavy screens normally used to deflect radiation beams from portable X-rays were extended to separate the soldiers from the protestors. I recalled the global media frenzy as I looked at the empty stretchers. At the epicenter of the furore, doctors and nurses must have worked intensely to mitigate the damage from the injuries. I could imagine the pressure they were under. The surroundings looked much like the American and Saudi emergency rooms where I had spent nearly fifteen years of my own career treating the critically ill, the catastrophically wounded, resuscitating the arrested, and often pronouncing death on those we couldn’t save only to deliver the news to terror struck relatives huddled nearby. But never had I attended my patients during combat, treated others while I might fear for my own safety. That would require a courage I wasn’t sure I had.

It had been my years in Riyadh, Saudi Arabia (where I practiced critical care medicine in the flagship military medical institute for the Saudi Arabian National Guard) that had introduced me to the architecture of combat-readiness and awareness of the proximity of the strangest bedfellows throughout the ages: that intimate pairing of medicine and mortal combat.

While the massive Riyadh National Guard Health Affairs hospital was blast-proof, awash in funding and manpower, rumored to have even its own satellite laid on a sprawling complex looking out onto the Najd desert and entirely constructed on a single level- (imagine a quaternary level hospital without elevators) it wouldn’t be until later in my career, when I concerned myself with academic freedoms, that I would learn the best protections from conflict are not found in the mortar binding walls but the intellectual pursuits practiced in the spaces within.

In Riyadh on the way to my critically ill patients – many of them Saudi soldiers or military families — I had walked in the lonely seven-meter wide marble corridors. More Saudi opulence I thought to myself, until a more seasoned physician explained to me that in the event of combat, were there to be a bombing of some kind and our wards reduced to rubble, patients could still be aligned against each wall, and attended either side of the corridor, with sufficient room in between for physicians like us to make rounds in between. It was a stark reminder that much of the disease and suffering we physicians are likely to see will be inflicted not by fate or genetics but deliberately by our fellow humanity.

Fifteen years later, I find myself in the same time zone as Riyadh, a few hundred miles to the northwest, yet I am in the alternate universe that is Israel. Tentatively I make my way down the steep gradient of deep gratings designed to allow rain and debris to drain away as I enter the mouth of what looks like a massive Manhattan parking garage.

We descend below sea level in the wide, permanently illuminated staircases (Photo: courtesy Qanta Ahmed)

We descend below sea level in the wide, permanently illuminated staircases (Photo: courtesy Qanta Ahmed)

My companion for the day, Emmanuel Kain, fourth year civil engineering student, kindly carries my handbag and offers me his arm to balance my foolish heels. And thus, precariously and curiously, I enter the whale-like mouth of the belly that is the Samy Ofer Fortified Emergency Hospital.

The bright Haifa sunlight is soon a diminishing rectangle as we are bathed in fluorescence. We are dwarfed by the scale of this shelter, a shelter where this will become, like all hospitals, a space full of pain and relief and Israel will ask of her citizens extraordinary heroism.

I tour the empty hospital with the humble yet dogged chief engineer who has seen this operation to realization. At first, uncertain of his English he is reluctant to speak but as he sees my curiosity he soon forgets his hesitation and I begin to see the fortified hospital through his eyes.

I study the surroundings both as a former critical care physician and as the daughter of a British architect. The latter delights the Chief Engineer in particular and he allows himself a rare smile. Israel’s Samy Ofer Fortified Emergency hospital is impressive: three below-ground levels, each 200,000 square meters in area finished in high grade, squeaky epoxy flooring. We climb up and down specially designed, extra-wide stairwells, permanently illuminated. I immediately think of Charity Hospital in New Orleans during Hurricane Katrina and remember the hardships of narrow dark stairwells stagnant with floodwater. Here in Haifa, these staircases stand ready to receive a high speed influx of patients caught in live combat, some maybe walking, others stretchered, who will be cared for 16.5 meters below the Mediterranean. The levels are demarcated in negative digits, Level -1, Level -2, Level -3. Sensing the weight of the sea, I feel secure in this fortress.

Each level is 200,000 square meters in area, color coded to define patients with different needs (Photo: courtesy Qanta Ahmed)

Each level is 200,000 square meters in area, color coded to define patients with different needs (Photo: courtesy Qanta Ahmed)

Here patients and staff will be protected from conventional, chemical, and biological warfare around them while they work to meet the needs of the community and those wounded in war. A feat of extraordinary engineering, in peacetime the facility operates as a parking lot with a capacity of 1340 cars, where only the most observant of drivers would notice the concealed panels housing power outlets for the medical monitors, the oxygen and suction hook ups and color coded lines which will transform the underground garage into a full blown level one trauma center come war.

Concealed panels reveal hook ups for oxygen, suction, medical monitors (Photo: courtesy Qanta Ahmed)

Concealed panels reveal hook ups for oxygen, suction, medical monitors (Photo: courtesy Qanta Ahmed)

In short order, this 2000 bed hospital can contain and support 1000 patients normally housed in the Rambam medical center above ground who are likely to be admitted for routine care when conflict begins, and still accommodate a further 1000 acute casualties, even the most critically ill injured in war. The hospital is sealed into various sections underground, massive steel doors weighing 15 tons apiece separate categories of patients, places where patients can be routinely dialyzed, emergently operated upon, or lethally wounded, even maintained on full life support. I try to move the doors, but the Chief Engineer shakes his head, the mechanism is computerized, the sealing of the doors will be mechanized. I am reminded of the pyramids I am yet in this lifetime to see.

Steel Doors, weighing 15 tons apiece, section off areas below ground (Photo: courtesy Qanta Ahmed)

Steel Doors, weighing 15 tons apiece, section off areas below ground (Photo: courtesy Qanta Ahmed)

At the gaping mouth through which I entered, the entire facility can be sealed from the external world at war in the face of conventional and unconventional warfare including chemical and biological weapons. The hospital can sustain itself using banks of generators with its own power for a full 72 hours. While there are smaller versions of such facilities in Sweden (where NATO is headquartered), and Singapore, which has a 400 bedded underground facility, Israel’s 2000 bed capabilities found in the Samy Ofer Fortified Emergency Hospital are the largest and most advanced in the world.

In my four visits to Israel to date, I have seen the extraordinary architecture that defines Israel to the world — the Western Wall, the Dome of the Rock, the palaces of Herod, the fortress of Masada, the wall of separation, and the sobering spaces of Yad Vashem. Each has affected me deeply, as a woman, a traveler, a believer, a writer.

But it is as I toured the center two days before its official live rehearsal, with full staffing and simulated patients, that I understood Israel in the silence of the empty spaces of the Samy Ofer Fortified Emergency Hospital. Making my way back above ground, I listened to the ricocheting echoes of my own footfall. I was dwarfed in this ark which has space for all in need. And in that silence and in that space, I was at once profoundly impressed yet deeply perturbed.

At last I understood what my Israeli friends -many of them combat veterans and seasoned soldiers themselves – have long explained to me. Israel is heavily invested in the knowledge of future combat. This knowledge is not in the sense of an abstract threat, but as a real likelihood. And unlike other nations, Israelis as individuals and as a society approach this challenge, rather like nearing a fire-breathing dragon with a gift in its mouth- pragmatically, and with a cool head, knowing there is a prize at the end.

Each of us stands where a patient would be placed. The Chief Engineer is on right (Photo: courtesy Qanta Ahmed)

Each of us stands where a patient would be placed. The Chief Engineer is on right (Photo: courtesy Qanta Ahmed)

The Sammy Ofer Fortified Hospital has been conceived, constructed and fully functional less than eight years after the Israel-Lebanon conflict unfolded. Knowing that war with Hezbollah or another will come again, Israel faces terrible certainties to live with, but live with them the Israelis must. In doing so, rather like the dogged humble chief engineer, with little fanfare and even less ceremony, they have gifted their community with a protection as silent and secure, a shelter as iconic as the basket Moses was once ensconced within, a hold as deep, and fortified as the one Noah’s wordless flock once nervously sheltered within, a cavity as dark and shielded as bereft Jonah was kept safe from the stormy seas without.

While the storm may indeed be once more gathering around the continuing miracle that Eretz Israel is for all mankind, one thing is for sure: in time the skies will clear overhead, Israelis will emerge battlescarred, but whole, and within the Samy Ofer Fortified Hospital they will have fully met their nation’s invitation to storied heroisms that others will long remember.