Are there ‘two sides’ to attacks on healthcare? Evidence from Palestine

European Journal of Public Health, 1–2
 The Author(s) 2021. Published by Oxford University Press on behalf of the European Public Health Association.
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Are there ‘two sides’ to attacks on healthcare? Evidence from Palestine
In June 2018, 20-year-old medic Razan al-Najjar was shot and killed
by an Israeli sniper as she tended to protestors on the border between
the Gaza Strip and Israel. Despite efforts to obscure Razan’s
motivations, with an Israeli spokesperson claiming she was ‘not the
angel of mercy Hamas propaganda is making her out to be,1’ eventually
Israel admitted that her death was unintentional and a rigorous
New York Times investigation found that the medics and others
in the immediate area posed no threat to Israelis2. Although Razan’s
murder made international news, the World Health Organization
(WHO) reported 431 other attacks against healthcare in the occupied
Palestinian territories (oPt) in 2018.3
Just as acts targeting health infrastructure are condemned when
committed by regimes seen as hostile by the West, the international
medical community must speak out forcefully when they are performed
by states viewed as allies. This is particularly true when our
governments are providing significant military aid to these countries,
as in the case of the USA4 and the European Union,5 which
collectively supply Israel with billions of dollars in such aid annually.
For decades, there have been dozens, and often hundreds, of
attacks on Palestinian healthcare from Israeli military forces
reported annually. But to the medical community, these attacks
are not mere numbers. In May 2021, a former colleague of one of
the authors of this article was killed in the Gaza Strip. Dr. Ayman
Abu al-Ouf, head of internal medicine at al-Shifa Hospital and the
coordinator of the hospital’s COVID-19 response, died when Israeli
bombs struck his home an hour after he left his shift at the hospital.
Dr. al-Ouf was more than a work colleague; he was an inspiring
figure who had mastered his profession and saved many lives. ‘His
death is a catastrophe’, said one of the physicians he trained.6
The recent cycle of Israeli military aggression on the besieged
Gaza Strip has caused colossal damage to the already worn-out
healthcare system. Six hospitals and nine clinics, including a trauma
clinic run by Me´decins Sans Frontie`res as well as the main COVID-
19 laboratory in Gaza, were damaged.7 As with other attacks on
Gaza, the true damage to the infrastructure of roads, water and
sanitation facilities, electricity, and other resources vital to health
remains to be discovered. Simultaneously, Israeli troops invaded Al
Makassed Hospital in East Jerusalem and blocked ambulances of the
Red Crescent responding to protests at the al-Aqsa mosque. From
May 7–20 alone, the WHO reported 117 attacks on healthcare across
the West Bank and Gaza.8
Civilian medical facilities, personnel and ambulances are offered
special protections in international humanitarian law (IHL), as mandated
in the Geneva Conventions and supported by multiple resolutions,
statutes and statements since. Article 19 of the Fourth
Geneva Convention states that hospitals retain these protections unless
actively engaged in ‘acts harmful to the enemy’. Loss of civilian
life and damage to civilian infrastructure must also be weighed in
such decisions. Yet the vagueness of this provision allows belligerent
actors to make unsubstantiated claims of military uses, such as the
hospital being utilized as a ‘human shield’. This justification has been
given even as hospitals were clearly used for civilian purposes, with
some bombings occurring as facilities were full of patients.
Israel regularly claims that the dozens of medical facilities bombed
in Gaza are attacked because they house militants or arms. In some
cases, the bombing is considered collateral damage for attacks on
nearby facilities thought to be holding militants. In others, the Israeli
military admits a target was a mistake. This reveals the entire premise
of Israel’s approach to security: that their actions should be
construed solely as self-defense in ongoing warfare, with the other
side equally if not more culpable for attacks on its own people.
After multiple massive assaults on Gaza, and regular violence
against Palestinians across the oPt, medical and public health professionals
tasked with protecting human life should take the lead in
questioning whether Israel’s aggressive use of military force against
medical infrastructure and personnel, under the guise of selfdefense,
is acceptable. The lack of evidence provided to justify these
numerous attacks begs the question of how many would qualify as
self-defense under IHL if Israel was independently investigated.
Israel’s past internal investigations have led to almost no repercussions
or admissions of wrongdoing.
The bombing of healthcare facilities and medical staff is only the
most visible of the systematic violence towards Palestinian healthcare.
As the Occupying Power throughout the oPt, Israel has specific
duties to provide for and protect Palestinian health and medical
needs ‘to the fullest extent of the means available to it’ according
to the Geneva Conventions. Yet years of occupation, segregation,
building walls and checkpoints, restrictions on freedom of movement,
and an illegal siege in Gaza systematically weakens and dedevelops
the Palestinian healthcare system. Israel’s attacks on health
across the West Bank and East Jerusalem include the raiding of
hospitals, the blockage of ambulances and other physical attacks
or barriers. In June 2021, Israel shut down one of the largest health
care service providers in the West Bank for purported political
affiliations.9 Such closures, restrictions and other targeted disruptions
of Palestinian healthcare should be viewed as akin to physical
violence—as violations of Palestinian health that are tantamount to
collective punishment.
While we have been interrogating whether the concept of selfdefense
might apply above, many legal scholars do not accept that
Israel has such a right under international law. A state cannot simultaneously
control and occupy a territory while claiming to be
under attack from that territory as a foreign threat.10 Israel’s duty
to protect Palestinians under occupation has a much stronger legal
basis than any purported right to self-defense, particularly one that
in practice leads to killing those who require said protection.
Leaving aside the question of whether self-defense can legally justify
attacks on the Gaza Strip, there is ample documentation that many
of the large-scale bombings, exhibiting the latest in modern weaponry,
are carried out with no such purpose.
The 2021 attacks on Palestinian healthcare workers and facilities
are therefore not isolated incidents but represent a pattern of illegal
targeting, which may amount to war crimes. In response, the
International Criminal Court has recently opened an investigation
into these and other potential crimes in the oPt since 2014, and the
United Nations Human Rights Council voted to open an investigation
on violations of IHL after this latest assault. While too many
lives have been lost, it is not too late for the international community,
including health professionals, to change course and demand
Conflicts of Interest
None declared.
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1 Pileggi TJ. After saying it shot medic by accident, IDF claims she was ‘no angel’.
The Times of Israel 2018. Available at:
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2 Halbfinger D. A day, a life: when a medic was killed in Gaza, was it an accident?
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middleeast/gaza-medic-israel-shooting.html (22 June 2021, date last accessed).
3 WHO. Right to Health in the occupied Palestinian territory, 2018. Available at:
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6 Shaikhouni L. ‘His death is a catastrophe’: Gaza doctors mourn specialist killed in
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57148580 (24 June 2021, date last accessed).
7 Mahase E. Gaza: Israeli airstrikes kill doctors and damage healthcare facilities. BMJ
8 WHO. (2021). Escalation in the occupied Palestinian territory. Available at: http://
date_May_20.pdf (22 June 2021, date last accessed).
9 Amnesty International. (2021). Israeli army shutdown of health organization will
have catastrophic consequences for Palestinian healthcare. Available at: https://
ization-will-have-catastrophic-consequences-for-palestinian-healthcare/ (23 June
2021, date last accessed).
10 Erakat N. No, Israel does not have the right to self-defense in international law
against occupied Palestinian territory. Jadaliyya 2014; Available at: https://www. (23 June 2021, date last accessed).
Yara M. Asi1, Osama Tanous2, Bram Wispelwey3,4,5,
Mohammed AlKhaldi6,7,8
1 School of Global Health Management and Informatics, University of Central
Florida, Orlando, FL, USA
2 Rollins School of Public Health, Emory University, Atlanta, GA, USA
3 Brigham and Women’s Hospital, Boston, MA, USA
4 Harvard Medical School, Boston, MA, USA
5 Health for Palestine, West Bank, Palestine
6 Faculty of Medicine, McGill University, Montreal, Canada
7 Swiss Tropical and Public Health Institute, University of Basel, Basel,
8 Faculty of Medicine and Health Sciences, An-Najah National University,
Nablus, Palestine
Correspondence: Y.M. Asi, School of Global Health Management and
Informatics, University of Central Florida, 500 W Livingston St, Orlando, FL
32801, USA
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