POSITION PAPER
“Civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack, but shall at all times be respected and protected by the Parties to the conflict.”(Geneva Convention (IV) on Civilians, 1949 – Article 1)
This position paper addresses Israel’s recurrent military strikes on medical facilities, personnel, and infrastructure in the Gaza Strip. These systematic attacks have decimated Gaza’s healthcare system, severely devastating its capacity to respond to the escalating needs of patients and the wounded. Accordingly, Israel’s actions must be investigated as war crimes. Furthermore, the evacuation of patients from the Gaza Strip has been considerably impeded, demonstrating a blatant disregard for their urgent needs. These conditions have intensified the strain on an already overburdened healthcare system, which, even before the war, struggled with the severe limitations imposed by Israel’s military blockade on Gaza. The recent military campaign dealt a catastrophic final blow to Gaza’s healthcare system and its population during one of its most challenging periods in history. This position paper presents two key arguments: (1) Israel has effectively destroyed Gaza’s healthcare system. (2) The massive devastation was accompanied by a defamation campaign against the healthcare system, aiming to undermine its credibility and professionalism despite a lack of evidence supporting such allegations (cases in which evidence was presented and verified by an impartial third party will be discussed later in the document.) Israel has shifted its approach from a policy of de-development to a strategy of complete destruction.
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Dear friends,
The healthcare system is a pillar of social solidarity, critical to a society’s capacity to sustain itself. The combination of the words “health” and “care” emphasizes its fundamental role in mutual accountability – a system inherent to human existence, from birth to life’s final moments. It is a system that delivers, saves, and preserves lives.
Gazan society has been in crisis since 1948, when it absorbed a refugee population three times the size of its own. These refugees were settled in eight refugee camps, and for the past 75 years, successive generations have grown up in poverty and oppression. Fifty-six years of military occupation have exacted an additional heavy toll on Gaza’s residents, both as individuals and as a community. Over the course of decades, Israel stifled any Palestinian attempts at social and political organization in Gaza, severely harming the local educational, economic, judicial, and welfare systems. Moreover, Gaza has grappled with an ongoing crisis stemming from the detrimental consequences of a sixteen-year blockade. Beyond adversely impacting the physical and mental well-being of over two million residents, Israel’s blockade of Gaza has fundamentally eroded the capacity to maintain local institutions crucial to the functioning of a society.
Amid this harsh reality, Gaza’s healthcare system proved to be a resilient space of survival for both individuals and society as a whole. Beyond providing patient care, it has acted as a space for mutual aid and a trusted public institution while instilling hope in society’s resilience even amid the most challenging circumstances.
The circumstances in Gaza are indeed dire. Israel’s occupation has prevented the capacity to administer various treatments, including chemotherapy for over 2,000 cancer patients in Gaza. It has also prevented healthcare professionals from participating in trainings, conferences, and continued education programs outside the Gaza Strip. The healthcare system in Gaza grapples with severe shortages of essential medical supplies and almost half of the required medications, critically impairing its capacity to function. Amid these conditions, the
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residents of Gaza face an ongoing public health crisis, grappling with a lack of drinking water, electricity, and food security. Additionally, they are subjected to frequent military attacks that harm medical facilities and personnel, resulting in countless physical and mental injuries.
Yet despite all this, our work in Gaza has introduced us to dedicated health professionals, their patients, and inspiring local communities. Over the past 14 years, approximately 100 PHRI volunteer delegations have provided medical care, performed operations, and transported supplies and medications to Gaza. Our primary efforts have centered around providing professional training and capacity building for healthcare professionals, including training in eye, knee, and kidney transplant surgeries for physicians and trauma-informed care for local mental health therapists. The remarkable determination of local professionals to further educate themselves and enhance their care services for the people of Gaza, along with the patients’ confidence in them, have taught us valuable lessons on social resilience and the indispensable role of the healthcare system in Gazan society.
On October 7, Hamas-led militants carried out a murderous attack with the explicit intent of targeting civilians. Hundreds of men, women, and children were slaughtered, and among the 250 Israelis who were taken hostage, 129 are still being held in Gaza. Following the assault, Israel launched a military offensive in Gaza marked by unprecedented brutality, leading to more than 28,300 casualties to date, including more than 12,300 children.1 Since its outset, Israel’s military campaign in Gaza has involved deliberate and systematic assaults on local healthcare infrastructure. Israel’s latest aggression has escalated the already dire humanitarian and health crisis in Gaza, severely impairing Gazans’ capacity to continue surviving. As early as 2012, the UN published a special report cautioning that Gaza would no longer be inhabitable by 2020.
This report and subsequent ones have underscored the obliteration of the healthcare system as a pivotal factor leading to the descent into an irreparable crisis. As demonstrated in this position paper, Israel’s current military aggression, its most ruthless since 1948, has resulted 1 The number of causalities and wounded in this position-paper are updated as of February 12, 2024.
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in the total collapse of Gaza’s healthcare system and an unparalleled humanitarian catastrophe.
Apart from causing physical and psychological harm to residents, the direct attack on Gaza’s healthcare system is also proving lethal to local society. The inability to provide care for wounded and dying patients is not just a human disaster; it also reflects the breakdown of systems of trust and mutual aid. Medical personnel rendered helpless amid the pleas of the injured and their families, the evacuation of medical facilities with patients left behind, non-operational hospitals, and a local population left to face their own fate – all signify the disintegration of community networks that constitute the essence of social existence.
The local and international medical community must take a stand and resist. Our unique comprehension of the ramifications of denying healthcare compels us to insist that the destruction of Gaza’s healthcare system contradicts ethical standards, violating the right to life and the core principles of care and compassion inherent in the medical profession. We must advocate for saving lives and the immediate rehabilitation of Gaza’s healthcare system and society. We must demand a ceasefire, the release of all hostages, an end to the blockade, and the pursuit of a peaceful political resolution that ensures safety, freedom, and equality for everyone between the river and the sea.
Yours sincerely,
Dr. (PhD) Guy Shalev Executive Director, PHRI
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Background
Following the Hamas-led attack on towns in southern Israel on the morning of October 7, 2023, Israel launched a military offensive on the Gaza Strip. As of Feb 12, 2024, the toll stands at more than 28,340 dead with 67,984 individuals injured, close to two million displaced, and an unknown number still missing, with many presumed to be buried beneath the rubble of bombed structures. Given the gravity of the crisis, the importance of a functional healthcare system is paramount, as it plays a pivotal role in treating the injured and the ill and addressing public health concerns. It is, therefore, imperative to examine the repercussions of Israel’s military aggression within this context.2
The magnitude of Israel’s attack on Gaza’s healthcare system is evident in a flash update issued by the Palestinian Ministry of Health outlining the war’s outcomes until the end of 2023: 142 health facilities were targeted, resulting in 30 hospitals and 53 clinics losing functionality. Additionally, 326 healthcare workers were killed, 350 sustained injuries, and 99 were arrested.3 Hospitals in the northern Gaza Strip were rendered entirely inoperative for extended durations, even as the number of wounded individuals continued to increase. The hospitals that could subsequently resume operations did so with limited capacity.4
The Israeli assault caused unparalleled damage to Gaza’s medical infrastructure. At present, only eight out of 36 hospitals and medical facilities in Gaza are operational, and they are severely understaffed, lacking essential equipment,5 and functioning at twice their capacity.6 The hospitals and medical facilities have been incapacitated due to multiple factors, including encirclement by Israeli military forces impeding staff movement; a critical shortage of fuel, electricity, and medicine resulting from Israel’s complete blockade on the Gaza Strip; and incidents of direct firing and military invasions. Evacuation orders
2 https://www.emro.who.int/images/stories/Sitrep_-_issue_19.pdf?ua=1
3 Palestinian Emergency Operation Center, Palestinian Ministry of Health – Gaza Strip 2023,
1 January 2024.
4 Gaza: ‘Endless needs’ reflect spiralling situation as hospitals shut down, WHO warns | UN News
5 WHO pleads for immediate reversal of Gaza evacuation order to protect health and reduce suffering 6 https://www.emro.who.int/images/stories/Sitrep_-_issue_17_for_review.pdf?ua=1
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have been issued for more than 22 medical facilities in the northern Gaza Strip.7 Furthermore, based on reports from the Palestinian Ministry of Health, 52 out of the 72 clinics in the Gaza Strip have ceased operations, with the rest functioning only partially. According to the World Health Organization (WHO), the incapacitation of hospitals has resulted in a severe decrease in the number of beds, dropping from 3,500 before the war to 1,400 at present.8 This has considerably impeded the local healthcare system’s capacity to respond to the needs of the countless sick and wounded residents.
This massive and extensive damage over recent weeks indicates that the hospitals in the northern Gaza Strip have become a deliberate target. According to data and testimonies collected by Human Rights Watch, Al-Quds Hospital, Al-Nasr Children’s Hospital, and the International Eye Care Center were all targeted within the first month of the war, resulting in the complete destruction of the latter. Al-Rantisi Children’s Hospital, Al-Shifa,9 and the Indonesian Hospital10 were also damaged in the bombardments. Numerous patients, their relatives, and thousands of displaced individuals who sought refuge in the hospitals were either killed or wounded. As a result, the hospitals, intended to be safe havens, not only lost their capacity to provide patient care but frequently turned into death traps.
This position paper examines the current state of Gaza’s healthcare system following the military aggression, as well as Israel’s role in harming it. We argue that Israel’s assertions about the loss of protected status for medical facilities do not warrant the extensive and deliberate destruction that ensued, and that Israel’s actions should be investigated as a violation of international humanitarian law and as a war crime.
7 Human Rights Watch, “Gaza: Unlawful Israeli Hospital Strikes Worsen Health Crisis”, November 16, 2023.
8 https://www.emro.who.int/media/news/who-appalled-by-latest-attack-on-indonesian- hospital-in-gaza.html?vaer=1
9 Hostilities in the Gaza Strip and Israel | Flash Update #35 [EN/AR/HE] | OCHA (unocha.org) 10 Hostilities in the Gaza Strip and Israel | Flash Update #45 [EN/AR/HE] | OCHA (unocha.org)
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Analysis of the damage to Gaza’s hospitals
Israel provided two main justifications for its assaults on Gaza’s hospitals. Firstly, it asserted that the hospitals were given evacuation warnings to safeguard the lives of both staff and patients. Secondly, Israel argued that the hospitals lost their right to special protection because they were being used as Hamas command centers. However, Israel’s reasoning misrepresents the actual circumstances on the ground. Evacuating large hospitals, especially those dealing with complex medical cases, requires a safe and professional process and adequate alternative facilities to accommodate the evacuated patients. These essential conditions were not met.11 For instance, Al-Quds Hospital sought assistance from PHRI after being instructed to evacuate on October 29 without being presented with viable alternatives for patients. The petition we submitted in response was subsequently rejected, with the court signaling that the military had been granted a carte blanche to act with impunity: “A petition was submitted demanding to limit the Israel Defense Forces’ freedom of action amid its efforts to protect the citizens of Israel. War-related court petitions are categorically dismissed to prevent the overburdening of the government branches and the need to address such petitions while our enemies hunt us in the north and the south.”12 Meanwhile, during the temporary ceasefire at Al-Nasr Hospital, when staff returned after being instructed to evacuate along with patients, five premature newborns were found lifeless.13
The WHO had raised alarms about the grave danger posed to the lives of patients and displaced individuals, especially vulnerable patients “cut off from life-saving medical attention,” following Israel’s orders to evacuate to the southern Gaza Strip. The organization highlighted a shortage of emergency vehicles and hospital beds in the medical facilities of southern Gaza, making it difficult to transfer and treat patients adequately. Israel’s evacuation orders were thus deemed
11 Human Rights Watch, “Gaza: Unlawful Israeli Hospital Strikes Worsen Health Crisis”, November 16, 2023.
12 Petition No. 6724-23.
جثث أطفال رضع متحللة بمستشفى في غزة تصدم العالم | أخبار | الجزي�رة نت 13 (aljazeera.net)
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“a death sentence for the sick and injured,” endangering the lives of thousands and undermining the capacity to provide medical care in Gaza.14 The evacuation orders, issued in the face of the imminent collapse of Gaza’s entire healthcare system, worsened its ability to handle the overwhelming challenges it was confronting.
Consequences for patients
Beyond the devastating influx of critically wounded patients – a challenge even Israel’s advanced healthcare system struggled to cope with – the hospitals in Gaza also had to continue providing routine and ongoing care to patients reliant on their services. They inevitably collapsed under the burden of the countless severe cases, tending to the needs of displaced individuals seeking refuge, grappling with shortages of essentials such as fuel, electricity, water, and medical equipment, and dealing with fatigued and depleted personnel. Among the groups most adversely affected were patients requiring continuous care, particularly those undergoing cancer and dialysis treatment.
Cancer patients: There are 2,000 cancer patients in the Gaza Strip, including 122 children.15 In early November, the Turkish-Palestinian Friendship Hospital for Cancer was bombed by Israel, leaving hundreds of patients without medical care. Hospital Director Dr. Subhi Sakik reported that four patients died on the night of the patients’ evacuation to the nearby Shuhada al-Aqsa hospital, in addition to six patients who had died the previous night.16 The physician told Al-Jazeera that cancer patients had to evacuate the hospital 37 days into the war because the facility could no longer offer them sufficient care, thereby exposing their lives to increased risk. Some patients were transferred to the Dar Al Salam Hospital in Khan Younis, considered a safer option.
14 World Health Organization, Evacuation orders by Israel to hospitals in Norther Gaza are a death sentence for the sick and injured, October 13, 2023.
15 WHO (31 October 2023), Patients under siege in Gaza (Infographic). https://reliefweb.int/report/occupied-palestinian-territory/patients-under-siege-gaza- published-31st-october-2023
16 https://www.youtube.com/watch?v=e4beG3rPG-Y
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Even before the start of the war, the Palestinian Ministry of Health in Gaza was receiving hundreds of requests to leave Gaza for medical treatment due to the unavailability of care locally. Patients granted approval were primarily treated in hospitals in the West Bank and Israel. Israel, in numerous instances, would either delay or deny exit permits for patients,17 decline to issue long-term permits for those requiring continuous care,18 and prevent parents from accompanying their sick children.19 After the war began, circumstances grew even more strained, and the lack of critical cancer treatments, including chemotherapy, cost the lives of numerous patients. As Israel’s military aggression escalated, some patients were evacuated for treatment through the Rafah Border Crossing. While some traveled through Egypt to access medical care in Turkey, an unconfirmed number of patients remained in Gaza without receiving the necessary treatment.
Kidney disease patients: Before October 7, kidney disease patients in Gaza were being treated in six medical centers, where 13,000 dialysis treatments were administered monthly. Approximately 2,000 patients were referred to hospitals outside the Gaza Strip, mainly in Jerusalem, the West Bank, and Israel. However, due to the severe shortage of fuel and essential medical supplies since the onset of the war, the dialysis centers were compelled to reduce treatments from four to two hours for over 1,000 patients, including at least 30 children.20 The Health Ministry’s stock of dialysis filters, cannulas, and IV tubing was completely depleted, and the remaining supplies in hospital dialysis units were minimal. As rapid deterioration of kidney disease patients can occur in the absence of treatment, the shortage of medical supplies due to Israel’s siege and the attacks on Al-Shifa and Indonesian Hospitals were tantamount to a death sentence.21 Dr. Munir Albursh, director general of Gaza’s Health Ministry, noted in an interview that kidney disease patients had been dying daily due to the inability to receive treatment or travel to southern Gaza.22 Following concerted efforts during the temporary ceasefire, the dialysis unit at the Indonesian Hospital – equipped with only 20 operational machines – partially resumed functionality, along with Al- Shifa Hospital’s dialysis unit.
Consequences for the wounded
Through our regular communications with colleagues within Gaza’s healthcare system, we were confronted with the distressing reality unfolding in the hospitals. The devastation of the healthcare infrastructure and the incapacitation of Gaza’s major medical facilities have condemned the wounded to endure agonizing deaths from untreated injuries. In some instances, they died with family members by their side. In others, they were abandoned to face solitary deaths on the hospital floor, without medical personnel to treat them or anesthetics to ease their suffering, without access to water, and in dire sanitary conditions. The hospitals in southern Gaza that were still operational at the time also faced severe shortages of supplies and equipment, and it was nearly impossible to carry out surgeries under suitable conditions. The hospitals that remained functional in southern Gaza confronted critical shortages of supplies and equipment, and conducting surgeries under suitable conditions was nearly unattainable. In a webinar on December 11, Dr. Ghassan Abu Sittah from Al Ahli Hospital disclosed that Gaza’s healthcare system faced collapse already in the initial days of the war due to the severity and complexity of the injuries, remaining without supplies and with extremely limited capacities.23 Since then, tens of thousands more have been wounded, while the healthcare system has suffered a 70% loss of its capabilities due to Israeli attacks and the inability to replenish equipment. The critical supply shortage
21 https://reliefweb.int/report/occupied-palestinian-territory/public-health-situation-analysis- phsa-hostilities-occupied-palestinian-territory-opt-05-november-2023
22 https://www.youtube.com/watch?v=SOA49Oir8MM
23 A Conversation with Dr. Ghassan Abu-Sittah, December 11, 2023, Webinar, FXB
Center for Health & Human Rights at Harvard University. https://www.youtube.com/ watch?v=0dwN3J3gyjA
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included a lack of burn dressings and morphine for anesthesia and pain relief. Shortly before the ceasefire, the stock of ketamine and other anesthetics ran out as well. According to Dr. Abu Sittah, these conditions forced them to cease operations in the surgery room at Al Ahli Hospital. The medical staff then decided to travel to southern Gaza and assist the still-operational hospitals. The severity of the injuries, such as burns without shrapnel and limb amputations, emphasized to the physicians the intensity of the war.
Before leaving Al Ahli, the hospital’s physicians faced over 500 wounded patients with only two operating rooms, “essentially transforming us into glorified first responders. We only treated and operated on patients on the verge of death – carrying out procedures like opening airways, stopping bleeding from organs, and treating wounds that had penetrated internal organs – but nothing more. Many wounded people were left untreated… Large open wounds eventually became infected.” In his helplessness, Dr. Abu Sittah resorted to cleaning wounds with laundry detergent and vinegar – and without anesthesia.24
During the webinar, Dr. Abu Sittah emphasized the long-term consequences for the wounded, which will persist long after the war’s conclusion. With the healthcare system in ruins and no rehabilitation efforts in sight, those injured will face enduring chronic disabilities and a shortage of prosthetics. He cited estimates suggesting that between 900 and 1500 amputations were performed solely on minors, with some losing multiple limbs. This would present a significant burden even for an advanced and fully operational healthcare system, but for a collapsed system without its resources, it represents an insurmountable challenge.
Consequences for healthcare personnel
Medical staff found themselves caught in complex circumstances that prevented them from providing optimal care to the ill and wounded. Operating under the constant threat of attack poses impossible ethical and professional dilemmas. For example, amid their efforts to save lives, certain medical personnel received heartbreaking updates about the
24 https://time.com/6328314/gaza-doctors-hospital-electricity-fuel/
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loss and injury of their own family members, some even arriving at the hospitals where they were employed. They were consistently faced with the imminent threat of mortal danger. According to the Palestinian Ministry of Health, 326 health workers lost their lives, 350 were wounded, and 99 were arrested, with all contact subsequently severed. Some health workers discovered that their homes had been bombed, leaving them with nowhere to return. Others were faced with Israeli orders to evacuate hospitals despite having sick and wounded patients who could not be moved, including incubated preterm newborns, sedated patients in intensive care, and individuals with disabilities.
Despite their hospitals being targeted, some staff chose to remain with their patients, while others left to accompany those who could be evacuated. Physicians were forced to conduct surgeries in darkness, relying solely on the illumination from mobile phone flashlights. While acutely aware of the unsatisfactory hygienic conditions, they clung to the hope that they were, at the very least, increasing the likelihood of saving a life. Amputations were carried out on limbs that, under normal circumstances, could have been saved. The exhaustion endured by medical personnel and the trauma resulting from the harrowing conditions they confronted have repercussions on both their physical and mental health. These factors affect their professional performance and erode their confidence in their ability to fulfill their duties. They, too, are among the victims of Israel’s assault.
Public health consequences
The surge in patients and displaced individuals, along with power outages, fuel shortages, lack of safe drinking water, and insufficient medical supplies, imposed an immense strain on hospitals in northern Gaza, resulting in a devastating public health catastrophe. The gravity of the crisis prompted the WHO to issue a warning about the soaring risk of disease transmission in Gaza.25 The organization’s spokesperson stated that the rates of diarrhea among children in the sheltering camps
25 World Health Organization, Risk of disease spread soars in Gaza as health facilities, water and sanitation systems disrupted, November 8, 2023.
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exceeded 100 times the usual levels.26 Without available treatments, they faced the risk of dehydration and potential death. The risk of respiratory infections, chickenpox, and skin conditions similarly increased. Moreover, recent floods, causing the contamination of drinking water with sewage, presented the potential for a cholera outbreak. Numerous camps also documented cases of sexually transmitted diseases and urinary tract infections, with limited or no access to medical treatment. Women have resorted to sharing menstrual hygiene products and birth control pills, and those using intrauterine contraceptives have experienced bleeding and infections as a result of the unhygienic conditions.27
Israel’s lack of concern for this situation only slightly changed when it began impacting its own troops. Yet, even then, the warnings from Israeli health officials and the U.S. insistence on permitting the entry of fuel tankers to avert the collapse of sewage treatment facilities were contingent on security considerations: “We consulted with security officials to assess whether the decision adversely affects military objectives. The unanimous decision from all security branches was that it was feasible to accommodate the U.S. request.”28 As has been the norm for decades, the health of Palestinians was disregarded and entirely subject to Israeli “security considerations.”
Hospitals in southern Gaza
Upon the resumption of hostilities after the temporary ceasefire concluded on December 1, the assaults on hospitals in the southern Gaza Strip recommenced. This was exacerbated by an influx of wounded and sick persons arriving from hospitals that had ceased to function across Gaza, particularly in the north. As airstrikes and ground operations resumed, the hospitals in the southern Gaza Strip sustained significant damage, making access to them especially difficult. During a recent visit to Nasser Medical Complex in Khan Younis, a WHO team characterized the situation as catastrophic, noting that the medical center’s buildings
26 Devu Sridhar, It’s not just bullets and bombs. I have never seen health organizations as worried as they are about disease in Gaza, The Guardian, 29 December 2023.
27 https://www.hrw.org/news/2023/10/24/israels-unlawful-blockade-gaza-sparks-womens-rights-crisis 28 «Head of the National Security Council: We agreed to bring allow fuel into Gaza to prevent the spread of epidemics,” Ynet, November 17, 2023. [Hebrew]
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and grounds were “grossly overcrowded” with patients and displaced individuals seeking refuge.29 Amid an immense demand for healthcare services, the area is grappling with a critical shortage of medical staff. Physicians are exhausted, working tirelessly, and numerous patients are receiving treatment on hospital floors. According to data from the Palestinian Ministry of Health, hospital bed occupancy has reached 171%, and the Intensive Care Units (ICU) occupancy is 221%.30
Al-Shifa Hospital as a case study
In all instances where hospitals were targeted, Israel has failed to provide sufficient evidence to substantiate claims that the hospitals violated the terms of their protected status. One of the most widely discussed hospital attacks was the one that took place at Al-Shifa Hospital, Gaza’s largest and most advanced medical facility. Below, we detail the sequence of events during the assault:
November 3: The hospital’s primary generator ceased to function due to fuel depletion. The hospital continued operations using a smaller secondary generator, supplying electricity primarily to the ICUs, emergency room, and operating rooms. The shortage of medical supplies and the unsanitary conditions in the hospital heightened the risk of disease transmission and post-surgery infections. Reports indicated instances where wounds were exposed to flies and maggots, posing risks of tissue damage, bacterial infection, and sepsis.31
November 9: Israel escalated its bombardments near the hospitals in northern Gaza, with five documented strikes in the vicinity of Al-Shifa. These resulted in at least seven reported deaths and damage to the maternity ward and outpatient clinics.32
29 https://www.emro.who.int/media/news/who-appeals-for-protection-of-the-health-system- from-further-attacks-and-degradation-of-its-capacity.html
30 https://www.emro.who.int/fr/media/actualites/who-appeals-for-protection-of-the-health- system-from-further-attacks-and-degradation-of-its-capacity.html
31 https://www.ochaopt.org/he/content/hostilities-gaza-strip-and-israel-flash-update-28 32 https://www.ochaopt.org/he/content/hostilities-gaza-strip-and-israel-flash-update-35
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November 10: Ground forces effectively cut off northern Gaza from the south, leaving only a narrow corridor to the south. The ground assault intensified near hospitals as shelling and airstrikes continued. According to accounts from Doctors Without Borders and media reports,3334 patients and medical personnel were fired upon as they tried to flee Al-Shifa.
November 11: Israeli tanks surrounded the compound, blocking all entries, exits, and movement between buildings. Communication with hospitals in northern Gaza was cut off. Furthermore, the Indonesian Hospital and Al-Shifa experienced a power outage when their generators ran out of fuel. Consequently, two preterm newborns and ten patients lost their lives after their life support equipment ceased to function. Additionally, the 37 newborns in incubators and the dialysis patients were at risk of death. Al-Shifa’s director reported that the hospital had exhausted its supplies of food, water, and electricity. 15,000 people remained in the hospital, which had provided shelter to roughly 60,000 displaced persons since the war began.35
At this stage, the Israeli military declared that it was not causing harm to the hospital despite the ongoing combat in its vicinity, maintaining that it had established secure pathways for evacuations on the east side of the complex.36 Nevertheless, the reality on the ground was grim. Following intensified shelling starting around noon, three nurses lost their lives, and the cardiovascular facility and maternity ward sustained damage, along with the oxygen generator and several water tanks. Although many displaced individuals and some medical personnel managed to escape, others remained trapped inside, hesitant to leave
33 https://www.doctorswithoutborders.org/latest/urgent-patients-and-medical-staff-trapped- hospitals-under-fire-gaza#:~:text=At%20the%20time%20of%20this,%22They%20cannot%20evacuate 34 https://www.aljazeera.com/news/2023/11/11/we-are-minutes-away-from-death-gazas-al- shifa-hospital-under-attack
35 https://www.ochaopt.org/he/content/hostilities-gaza-strip-and-israel-flash-update-36
36 IDF Spokesperson statement, October 11, 2023. [Hebrew] https://www.idf. 16
due to reports of snipers positioned around the hospital.37 Some of the remaining patients were physically unable to evacuate on their own. The WHO reported that some individuals who used the “safe corridor,” secured by Israeli forces to facilitate the exit of those trapped in the hospital, found themselves caught in the crossfire, resulting in several fatalities.38
November 13: The director of Al-Shifa reported that they received instructions not to leave the hospital premises to retrieve bodies or provide medical care to the wounded in the surrounding area of the complex.39 With reports emerging of dozens of bodies beginning to decompose inside the hospital buildings, concerns about the potential for the spread of diseases and infections heightened. Following negotiations with Israeli forces, the hospital was granted permission to bury the bodies on that day. However, despite obtaining approval, the military hindered the burial process, forcing hospital staff to dig a mass grave in the courtyard of the complex for over 80 bodies.40 In an urgent plea to the State Attorney’s Office, PHRI requested to allow the evacuation of the wounded, preterm newborns, the ill, and displaced individuals seeking to leave, along with the evacuation and burial of all bodies, while avoiding any harm to those involved in these activities. As of now, we have not received any response to the request.
November 14: Days after imposing a complete siege and shelling its surroundings, Israeli forces entered Al-Shifa. They seized control of several hospital structures and bombed the area, including parts of the hospital itself, all while 7,000 displaced individuals, 1,500 medical personnel, and 700 patients, including 37 preterm newborns, were present inside. Dr. Muhammad Zaqout, the general director of hospitals in the Gaza Strip, told Al Jazeera that Israeli forces targeted the surgical and intensive care units and bombed a storage room for
37 https://www.ochaopt.org/he/content/hostilities-gaza-strip-and-israel-flash-update-38
38 https://www.emro.who.int/media/news/who-loses-communication-with-contacts-in-al- shifa-hospital-in-gaza-amid-reports-of-attacks.html
39 https://www.aljazeera.com/news/2023/11/14/gazas-al-shifa-hospital-forced-to-bury-dead- patients-in-mass-grave
40 https://www.who.int/news/item/18-11-2023-who-leads-very-high-risk-joint-humanitarian- mission-to-al-shifa-hospital-in-gaza
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drugs and medical supplies.41 Furthermore, military forces severed the connections between various buildings in the complex, conducted searches, and interrogated medical staff and patients, according to Palestinian Red Crescent spokesperson Raed Nims.
After the bombings and the siege, those still present within the compound were deprived of water, food, and electricity for several days. Without essential medical supplies, the hospital, usually capable of accommodating 600 patients, was rendered entirely non-operational. The spokesperson for the Palestinian Ministry of Health reported 40 fatalities in the hospital and extensive damage to medical equipment estimated at millions of US Dollars.42
November 18: Following the evacuation of numerous individuals from the medical complex, the Israeli military deployed additional troops and tanks around the hospital, heightening the pressure on the remaining medical staff and patients. Disturbing reports surfaced concerning the dire working conditions faced by the medical teams. Dr. Faisal Siam, the head of orthopedic surgery at Al-Shifa, was visibly emotional during an interview with Al Jazeera as he described having to amputate all four limbs of a four-year-old girl who survived the bombings.43 The surgery took place in a hospital corridor without the use of anesthesia. Dr. Siam also disclosed that, aside from a few exceptional cases, surgical operations in the department had ceased, with efforts shifting solely to providing first aid and disinfecting wounds. The wounds of amputation patients were infested with maggots, and the medical staff found themselves helpless due to the lack of critical medical supplies.
November 19: After Al-Shifa’s prenatal unit ceased to function due to power outages within the complex, physicians had no choice but to evacuate the surviving premature newborns from their incubators, exposing them to immediate danger. Despite multiple relocation attempts, it was not until November 19 that the WHO and the Palestinian Red Cross successfully transferred them to Tal al-Sultan Hospital in
41 https://www.youtube.com/watch?v=U6-0K-1GdO4
42 https://www.ochaopt.org/he/content/hostilities-gaza-strip-and-israel-flash-update-39 43 https://www.youtube.com/watch?v=NLRf2So1XGU
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Rafah.44 The subsequent day, they were transported to Egypt for medical treatment. With Al-Shifa crumbling due to a lack of vital resources such as clean water, fuel, medical supplies, food, and essential equipment, compounded by ongoing military attacks disrupting its operational capacity, it became crucial to evacuate everyone capable of leaving.
November 20: The Israeli military invited local and international media to the site to prove the existence of tunnels situated beneath the complex.
November 24: After medical staff at Al-Shifa requested to be securely evacuated along with patients and accompanying individuals, the WHO and the Palestinian Red Crescent executed a second evacuation mission involving 151 patients, their relatives, and healthcare workers.45 73 severely ill or injured patients were transported, including 18 undergoing dialysis, 26 with serious spinal injuries, 8 with severe chronic conditions, two requiring critical care, and 19 in wheelchairs. The patients were transferred in 14 ambulances provided and staffed by the Palestine Red Crescent, along with two buses with eight health workers and 70 relatives accompanying them. According to the WHO, the vehicles were held at a checkpoint for six hours, during which Israeli forces conducted searches on medical staff, patients, and their families. Three medical workers from the Palestinian Red Crescent and three Palestinian Ministry of Health employees, including Al-Shifa Director Muhammad Abu Salmiya, were arrested. Meanwhile, Israeli forces withdrew from the hospital’s buildings but maintained a presence in its vicinity.
November 27: After the withdrawal of the Israeli forces from the medical complex, the Palestinian Ministry of Health announced it had partially reactivated Al-Shifa’s dialysis unit. Kidney disease patients in the northern Gaza Strip were invited for treatment on Sundays, Tuesdays, and Thursdays.
44 https://www.who.int/news/item/19-11-2023-who-led-joint-un-and-red-crescent-mission- evacuates-infants-from-al-shifa-hospital-in-gaza#:~:text=Hospital%20in%20Gaza-,WHO%2Dled%20 joint%20UN%20and%20Red%20Crescent%20mission%20evacuates%2031,Al%2DShifa%20Hospital%20 in%20Gaza&text=A%20second%20WHO%2Dled%20joint,a%20hospital%20in%20southern%20Gaza
45 https://www.un.org/unispal/document/joint-un-mission-transfers-critical-patients-from-al- shifa-hospital-in-gaza-under-intense-fighting-who-press-release/
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Gaps between the military’s claims and the presented evidence
Israel justified the extensive damage to Al-Shifa Hospital by alleging that Hamas had utilized the facility for military purposes. These assertions were intensively communicated to local and international media, as well as international institutions and global leaders seeking to minimize the harm being inflicted. Therefore, it is crucial to thoroughly scrutinize Israel’s claims regarding Hamas’ alleged use of the hospital, especially those presented by Israel’s military spokesperson, and examine which have been confirmed by an impartial party.
As early as October 27, Israel’s military spokesperson asserted the following: “We exposed Al-Shifa Hospital to the world, revealing the underground infrastructure and how Hamas cynically exploited it for terrorist activities. We exposed the truth, and we will continue to do so.”46 The Israeli military’s website published an article titled “Evidence of Hamas’ Terrorist Operations Inside Gaza’s Largest Hospital,” featuring illustrative images, recordings of calls, and photographs that have not been verified by a neutral professional body. Following the Israeli military’s invasion of the hospital, their initial claims regarding Hamas activities on the site were tempered, now asserting that “the main headquarters are likely not located under Al-Shifa, and senior Hamas leadership are not hiding there.”47
At the time of drafting this position paper, no professional and independent experts have been able to access the hospital premises to scrutinize the military’s assertions. Consequently, we have reviewed the investigations carried out by media and international human rights organizations. The Washington Post’s investigation, relying on
46 IDF Website, «Watch the IDF Spokesperson’s statement», October 27, 2023. https:// www.idf.il47 Sapir Lipkin, «Hundreds of Hamas terrorists below Al-Shifa; Headquarters apparently not there», N12, October 7, 2023. [Hebrew]
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official sources, publicly available satellite images, and discussions with international law experts, led it to conclude that the evidence presented by Israel does not establish that Hamas utilized the hospital as a command-and-control center.48 The only direct evidence observed by journalists from various media organizations, including AP, the British Telegraph, and CNN, pertained to a tunnel beneath the hospital. Accompanied by the military, the journalists entered the tunnel and verified its existence. However, they were unable to validate the military’s assertions that the tunnel served as a Hamas control center. After journalists documented the tunnel, the military proceeded to detonate it, preventing international investigative bodies from inspecting it under professional and neutral conditions.
Israel’s claims regarding Al-Shifa Hospital did not originate in 2023. Similar allegations were made earlier, notably during Operation Cast Lead in 2008, when Shin Bet chief Yuval Diskin claimed that Hamas operatives were “hiding in hospitals, including Al-Shifa and a maternity hospital, with some of them wearing physician and nurse uniforms.”49 The hospital’s director at the time, Dr. Hassan Khalaf, refuted these allegations and expressed his concerns: “I genuinely hope that Diskin is not trying to lay the groundwork for a brutal assault on the hospitals. Such a move would be complete madness.”50 As Dr. Hassan anticipated, it seems that years of Israeli claims have laid the groundwork in both Israeli and global public opinion for the comprehensive attack on Al- Shifa observed in recent weeks.
Third-party testimonies by released hostages
Israeli hostages who have been released have substantiated the claim that Hamas allegedly holds hostages within hospitals, a charge the organization denies. For instance, Norlin Natalie Babdila reported that after 23 days in an apartment, she was moved to a designated area within Nasser Hospital in Khan Younis, where she encountered other
48 Loveluck, Hill, Baran, Ley & Nakashima, “The case of al-Shifa: Investigating the assault on Gaza’s largest hospital”, The Washington Post, December 21, 2023.
49 Daniel Adelson, «Gaza Hospital Director on Diskin’s Accusations: ‘Lies’,» Ynet, May 31, 2008. [Hebrew] 50 Ibid.
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hostages. The same account was independently reiterated by Doron Katz Asher, another Israeli hostage: “It was a hospital room. I saw another family I know there, my mother’s neighbors… Eitan Yahalomi and Erez Calderon, two 12-year-old boys who were held alone throughout those sixteen days.”51 Since Babdila named the same hostages, it is to be assumed that they were both describing the same hospital. These testimonies indicate that Hamas did make use of some hospitals. However, this does not warrant the scale of destruction inflicted upon this or any other hospital, resulting in the effective decimation of Gaza’s healthcare system.
The significance of the disparities between the military’s assertions and the resulting destruction
Any military actions conducted by Hamas in tunnels beneath hospitals endanger the lives of patients and medical personnel, violate their special protection, and should be subject to investigation as a war crime. However, and this is an essential point in any discussion regarding the protection of healthcare facilities and personnel, it’s vital to emphasize that any harm inflicted upon a hospital directly affects human lives. This is due to the detrimental impact on individuals present within the facility and the compromised capacity of the hospital to provide treatment to others in need. The total devastation inflicted upon Al- Shifa Hospital, along with the harm to staff, patients, and displaced individuals, and the hospital’s diminished capacity to address the escalating medical needs during the assault on Gaza, unequivocally points to an intolerable disparity between the real and perceived threats attributed to the hospital by the Israeli military and their corresponding actions in response. This discrepancy should be investigated as a potential war crime.
Most of Gaza’s hospitals, particularly those in the northern region, have been targeted based on Israel’s assertions that they were harboring
51 Doron Katz Asher’s testimony on N12. https://www.mako.co.il/news-israel/2023_q4/Article- 92812c6e6637c81027.htm?utm_sourceInstagram=&utm_medium=NewsChannelPageStory&partn er=NewsChannelInstagram [Hebrew]
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Hamas infrastructure, with the Al-Rantisi and Kamal Adwan hospitals explicitly singled out.525354 Yet, in none of these instances was evidence provided to an impartial third party or subsequently verified by such.
The devastation in Gaza, partially examined in this position paper, has led to a humanitarian catastrophe that will persist even after the conclusion of the Israeli offensive. As noted by Palestinian physician Dr. Ghassan Abu-Sittah, Israel has established a reality in which the disaster perpetuates itself. The healthcare system and critical infrastructure required for maintaining adequate sanitation and hygiene conditions have been obliterated, transforming Gaza into an inhospitable and deadly environment. This guarantees that those who evacuated under Israeli military orders will find no place to return, and those still remaining will be forced to leave.
Given the utter destruction inflicted upon Gaza’s healthcare system and the resultant loss of human lives, it is insufficient to merely demand proof that the hospitals have forfeited their protected status. We must also inquire: what evidence, if any, could rationalize such a catastrophic military offensive? How could such an attack ever be deemed proportional? The destruction of Al-Shifa provides an opportunity to examine Israel’s assault on Gaza’s hospitals within the
52 An article published on the IDF Website under the headline «Evidence that Hamas has turned hospitals into terror machines» includes documentation of a military operation that revealed the existence of combat supplies in the hospital›s basement.
54 IDF Website, «From the hospitalization ward to the basements: how Hamas turned Gaza’s hospitals into terror hubs.» undated.
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framework of international humanitarian law and substantiate the need for an investigation into potential war crimes.
Analysis and conclusions
Throughout fifty-six years of Israeli military occupation and sixteen years of blockade, the healthcare system in Gaza has sustained persistent damage. Israel has impeded its development, enforced strict restrictions on medical training, and limited the movement of patients and healthcare personnel for decades. Military offensives in 2009, 2012, 2014, and 2021, along with substantial damage during the 2018-2019 Great March of Return protests, have directly impacted health facilities and personnel, overwhelming an already fragile healthcare system with thousands of wounded individuals.5556
However, since October 7, we have observed unprecedented levels of Israeli military aggression, marked by a deliberate and systematic assault on medical facilities that has led to the total destruction of Gaza’s healthcare system. Only four of northern Gaza’s 24 hospitals remain partially operational. The hospitals in southern Gaza are overwhelmed by the vast number of injured and ill patients. According to the WHO, the number of hospital beds in Gaza has decreased from 3,500 to approximately 1,400. Concurrently, there has been a surge in the number of individuals seeking care in hospitals. At the same time, Israel persists in preventing the entry of essential medical supplies and crucial fuel for the healthcare system’s operations. Despite over 50,000 wounded patients in need of locally unavailable treatment, Israel continues to restrict their ability to leave Gaza for medical care in other countries.
Israel asserts it has evidence that Hamas is utilizing Gaza’s medical facilities for military purposes, thus forfeiting their right to protection. However, for 34 out of the 35 health facilities in Gaza, no neutral and independent body has confirmed these claims of military activity. Even if it were proven that Hamas used some medical facilities for military
55 Microsoft Word – short version report_PDFversion_.doc (phr.org.il) 56 PHRI_Report_Gaza-2014.pdf
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operations, the extensive destruction caused by Israel raises concerns that it is strategically undermining Gaza’s healthcare system to impair Gazan society’s capacity to exist. As demonstrated in this position paper, in the case of Al-Shifa Hospital, Gaza’s largest, although the existence of a tunnel within its grounds has been confirmed, Israel’s claims that it served as a Hamas control center could not be verified.
Israel bears the responsibility of providing evidence for every instance of its assault on a medical facility. It must furnish substantial evidence justifying the extensive and systematic harm inflicted upon Gaza’s healthcare system. This entails demonstrating that military activities have occurred in each facility and implicating the entire healthcare system in these actions.
In addition to directly targeting medical facilities, Israel has impeded the entry of crucial humanitarian supplies, restricted access to clean water, detained and killed healthcare workers, disrupted communications, and damaged infrastructure and roads. These actions have established an untenable reality in which the substantial rise in the number of wounded individuals and the acute public health crisis are confronted with a paralyzed healthcare system.
Medical facilities receive special protection under international humanitarian law and the laws of armed conflict for a crucial reason: even minor damage to a hospital can result in the loss of numerous lives. Consequently, even issuing an order to evacuate staff and patients should be regarded as a last resort. Each unaddressed violation of the protected status of hospitals and health facilities, coupled with the failure to demand accountability from the perpetrator or entity causing disproportionate destruction, undermines the safeguarding of health facilities in armed conflicts worldwide.
As the occupying power, Israel is obligated to guarantee the continuous operation of health facilities in Gaza and to protect medical personnel, the ill, and the wounded. Instead, Israel’s assaults and blockade have led to the imminent collapse of Gaza’s healthcare system at a time when it is most essential for the survival of thousands of wounded and sick individuals.
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Mere expressions of concern and condemnations from the international and medical communities fall short. Decisive actions are imperative to avert the complete devastation of the healthcare system in Gaza. The Israeli military must promptly, comprehensively, and conclusively lift the blockade, permitting the entry of essential supplies such as medicines, medical equipment, fuel, food, and clean water. Halting any additional harm to medical facilities is crucial to enable them to address the needs of the ill and the tens of thousands injured by Israeli bombings. Additionally, Israel’s extensive and systematic damage to Gaza’s healthcare system must be investigated as a potential war crime.
Writing and editing: Lama Bakri, Hadas Ziv, Guy Shalev and Ghada Majadli
The information provided in this document was collected from various sources, including global health and human rights bodies like the World Health Organization, the United Nations Office for the Coordination of Humanitarian Affairs, and Human Rights Watch. Additionally, valuable insights were acquired through dialogues with healthcare professionals working in the Gaza Strip.
