On the duty to protect the people of Gaza: how the collapse of the hospital health care system has reinforced genocidal intent

Attacks on hospital structures

As of January 20, 2024, of 36 functional hospitals in Gaza, only three were still fully operational (1). The remainder were either destroyed or partially functional due to direct military attacks, siege, deprivation of fuel, medical supplies, food, and water, and the killing (374 people) or detention (99 people) of personnel. This included the directors of hospitals, whose fates post-arrest by Israeli forces remain unknown (2).

The three fully functional hospitals, all located in southern Gaza, have limited capacity to meet the demand for beds, space, supplies, specialty care, and personnel. In particular, Al Nasser Hospital in Khan Yunis and the European Hospital in Rafah have also been the targets of indirect and direct bombings and are located adjacent to areas subjected to attacks, making access dangerous and difficult. Additionally, in the south, the Jordanian Field Hospital, Al Kuwait and Al Amal Hospitals, the Palestinian Red Crescent deposit of medical supplies and the ambulance parking area, and in the middle area of the Al Aqsa Hospital, recently suffered serious attacks (2).

Attacks on provision of specialized hospital care

Pediatric, primary, disability, chronically ill and cancer care, and dialysis are totally lacking in the north and insufficient in the south. Approximately 180 babies are born daily, few deliveries attended by clinicians, and only two neonatal intensive care units (NICU) are working. NICUs and maternity care were among the initial military targets at Al Shifa, Indonesian, Nasser Pediatric in Gaza and Nasser in Kan Younes hospitals (2,3).

Attacks on health care personnel and their resilience

Medical personnel have been working without a break for more than 3 months and are exhausted and demoralized, but no significant and adequate to need professional staff has been allowed to enter Gaza.

Since the beginning of the assault, medical staff decided to resist evacuation orders, keep the hospitals open for the influx of trauma and chronic patients and for thousands of displaced asylum seekers. This resistance costed often their lives, both of local health workers and of those with doctors without borders. Their resilience and refusal to leave until forced at gunpoint saved many patients (4). Many suggest these clinicians should receive the Nobel Peace Prize.

Attacks, effects on patients

Patients while reaching or in the yard of hospitals were attacked and those receiving care within the hospitals paid dearly as many injuries could not be properly treated for lack of supplies, became infected, and require amputations in order to save lives (4). Chronically ill patients did not receive needed medications and 1,200 dialysis patients including 45 children were unable to receive care (personal communication, director of Rantissi Pediatric Dialysis Unit, Dr. M. Anqar); their fate is unknown. Ten thousand cancer patients were under treatment at the Turkish Hospital, one of the first facilities to be bombed (4). They were referred to a smaller facility in the south which lacked drugs and therapeutic equipment.

Attacks on emergency health services

Ambulances were repeatedly directly attacked, leaving an inadequate number still working, with frequent and lengthy cuts to telecommunications further complicating their functionality. Fuel was often unavailable.

Ongoing endangerment of reproductive security

Normally,10% of the 5,500 babies born each month required NICU care (5), but those in Al Shifa, Al Nasser Pediatric, and Indonesian Hospitals are closed because of severe damage. Smaller NICUs, insufficient in size and services, remain. It is thought that the majority of approximately 1,500 fragile neonates born in the last 3 months with no access to care have likely died, unregistered, the absence of health care utterly invisible. Vaccinations were suspended, but recent attempts to revive the program have been challenged by difficulties tracing infants as 80% of the population is internally displaced with residence frequently unknown, often living in makeshift shelters, with unregistered births. Pregnant women are often unable to obtain antepartum, delivery, and postpartum assistance or medications and adequate anesthesia for cesarean sections and specialist surgeons are lacking (6). Women and babies have almost no hygiene supplies.

Denial of health of a whole population

The exponential increase in contagious diseases (7), most often in children, is challenging to address due to lack of supplies and opportunities for good hygiene. Common diseases in Gaza, like anemia, diabetes, and hypertension are also not being treated due to lack of medications and access.

Malnutrition bordering on starvation when unchecked will lead to difficulties in future development for children who survive, as well as the survival of adults. The World Health Organization (WHO) expects that almost a quarter of the Gazan population may die because of the blockade of goods and medications and lack of proper shelter (7). All UN organizations have deplored the major limitations in entry of supplies and roadblocks to humanitarian assistance that the Israeli military has created.

Perfect crime

This could be called a perfect storm, but it is more aptly named by United Nations (UN) agencies and experts a perfect crime (8).

This disaster is man-made, a cascade of measures that is leading to the injury and death of a large part of the civilian population, from the north to the south of Gaza.

The attacks on health care facilities are both forbidden according to international humanitarian law and the laws of war. These assaults affect the entire civilian population, leaving them unable to attend to their basic needs for survival, inflicting “collective punishment”. These attacks are considered genocidal because the deprivation is directed towards an entire ethnically, religiously defined population and because of the expressed intent and design to destroy or displace it (9).

The wide efforts to disable and destroy once and for ever the health care system since the beginning of this Israeli assault, by intentional destruction whole or in part of structures, targeted attacks to personnel into the wards, killings, and arrests of personnel are unambiguous examples of the genocidal policies. These come after years of blockade accompanied by enforced and explicitly stated containment of health care. South Africa instituted proceedings against Israel before the International Court of Justice (ICJ) on 29 December 2023, claiming that Israel has been acting in breach of its obligations pursuant to the UN Convention on the Prevention and Punishment of the Crime of Genocide (Genocide Convention), and made a first request for provisional measures (10) (as to January 26, 2024, the ICJ ordered provisional measures; available at https://www.icj-cij.org/sites/default/files/case-related/192/192-20240126-ord-01-00-en.pdf).

As professionals in health, and according to the inherent duty to protect lives, we embrace the urgent request of Gaza doctors

• To grant entry of medical supplies and fuel, adequate to the needs;
• To allow medical international teams to support the unsustainable workload;
• To allow passage out for more than 6,000 sick people that, as of today, cannot be treated in Gaza.

Summary of findings

There is widely documented evidence of deliberate, repeated, unlawful targeting of the hospital managed health care system, its structures, personnel, injured and chronically ill patients, reproductive needs, inaccessibility to the territory, denial of medical supplies, water, electricity, and food. There is excellent evidence for the direct targeting of oxygen production machines, solar panels, desalination devices in hospitals, the targeting of maternity and neonatal units, the obstruction and targeting of evacuation corridors and facilities for patients, all carefully documented by all UN bodies, nongovernmental organizations (NGOs), and the few foreign professionals working in Gaza. This assembly of facts is clear cut: the targeting of the health care system has been the “perfect crime” buried within a multitude of war crimes, targeting an entire civilian population, 70% women and children.

This reality does not occur by accident. It is not possible that, as the Israeli military claims without strong or independent evidence, most hospitals were “active command centers” for an armed enemy and an existential danger, a charge loudly denied by hospital staff and international volunteers.

The refusal by the Israeli government to accept an international investigation as requested by the local Ministry of Health and by independent NGOs and UN bodies, and the denial of access by the international independent press is deeply concerning. The rapid destruction by Israeli forces of the alleged “proof” that Hamas and militant factions were operating within or adjacent to hospitals, leaves as the only proof that provided by the self-produced Israel Defense Forces (IDF) videos and erases the opportunity to test the validity of Israeli claims.

We call, together with 153 countries in the General Assembly at the UN, all UN health and humanitarian agencies, health workers networks, and many millions in the streets, for the only solution: “immediate unconditional ceasefire now”, “stop the blockade of Gaza”, “immediate restoration of the health care system”, according to international laws and signed agreements. We also call for accountability, the repayment by Israel for the cost of repairing the damage for which they are responsible.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-11/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-11/coif). The authors have no conflicts of interest to declare.

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