Why Gaza health care facilities and workers have suffered so much violence

In a mere week, the fifth major conflict in the past 15 years between Hamas and Israel became its most catastrophic. Hamas’ slaughter of more than 1,200 Israelis represents the largest instance of the murder of Jews since the Holocaust. Hamas wounded another 3,700 Israelis and took more than 100 of them hostage.

Israel has responded with massive airstrikes that, as of this writing, have killed more than 1,900 Palestinians, including more than 450 children, and wounded more than 7,700 others, according to the Ministry of Health in Gaza, though this figure may include both fighters and civilians. More than 350,000 Gazans were displaced even before Israel ordered more than 1 million people to leave northern Gaza. The expected Israeli ground invasion will surely multiply the number of deaths and injuries to people living there.

Israel has expanded its long-existing land and sea blockade to include denial of food, water, electricity, and fuel coming into Gaza. The stock of medical supplies to treat the thousands of wounded and people with noncommunicable and infectious disease is quickly dwindling. Gaza’s power plant has run out of fuel. Hospitals, including Gaza’s largest, Al Shifa, are overwhelmed with patients, and they may have only a few days of fuel left to run generators essential for medical services.

The toll in lives and availability of health care has been made worse by 30 incidents of violence against health facilities, ambulances, and health workers in Gaza (a figure not yet verified) in the first five days of war. By the end of the first week, 10 health workers in Gaza had been killed, including four Palestinian Red Crescent Society paramedics in one airstrike. After Beit Hanoun Hospital in northern Gaza was damaged, it had to suspend services, leaving the town’s 36,000 residents without a hospital.

Violence against health care is hardly unique to this conflict. In Ukraine, Russia has attacked health facilities, ambulances, and health workers more than 1,000 times in a mere 18 months of war. Through late 2022, the Ministry of Health reported 144 hospitals were destroyed. In Myanmar, almost 800 health workers have been arrested since the 2021 coup. Overall, in 2022, there were almost 2,000 incidents of violence connected to health care in conflicts across 32 countries.

Nor is the violence against health care facilities and workers new to Gaza. In conflicts in 2009-10, 2012, and 2015, the World Health Organization reported that Israeli missiles, airstrikes, and tank assaults damaged or destroyed more than 200 health facilities and more than 150 ambulances. More than 30 health workers were killed on duty, more that 175 of them were injured. Gaza’s health system has never recovered.

Israel has repeatedly affirmed its commitment to the Geneva Conventions, including their requirements to respect and protect health care. The incidents during the first week of the war need to be investigated individually to determine if Israel violated the law, but it must be noted that numerous independent investigations have found breaches of its obligations in past Gaza wars.

Why has there been so much damage, death, and injury to health care workers and facilities in conflicts in Gaza? Airstrikes and ground fighting in a densely populated urban area inevitably result in civilian casualties and damage to health and other infrastructure. Israel has sometimes alleged that Hamas used hospitals for military purposes, but even if that is the case, it still has a legal obligation to minimize harm to civilians in them.

But these factors do not explain the extraordinary toll, especially given international humanitarian law requirements that combatants limit targeting to military objects and, where an otherwise civilian structure such as a hospital is also used for military purposes, avoid or at least minimize harm to civilians. Urban combat cannot account for the sheer number of attacks on ambulances and paramedics.

To seek an answer to this question, as part of my research for a 2021 book on violence against health care in war, I focused on why Israeli soldiers so often shot at ambulances during prior conflicts. I did so not only because of the high numbers and enormous impact of shootings on paramedics and people in dire need of emergency care, but because agreed-upon procedures had been established in Gaza and the West Bank to keep medical evacuation of the wounded and sick safe. Under the mechanism, the Palestinian Red Crescent society sent requests for ambulance entry to controlled areas to the International Committee of the Red Cross, which passed them on to the Israel Defense Force. When approved, the message was communicated back. Israeli troops could also inspect ambulances for weapons.

I found that in some cases, approval took so long, even multiple days, that paramedics, desperate to reach people with severe injuries, proceeded without permission. In other cases, ambulances were fired upon even after approval was granted. During Operation Protective Edge in 2015, a tank fired at an ambulance approved for evacuation, injuring the driver and two paramedics. Two of the men managed to get out of the vehicle by the time the tank fired again, but one of the paramedics, ‘Aabed al-Bura’I, did not and was killed. The IDF authorized a second ambulance to come to the aid of the injured men, but the tank fired at it, too, injuring its two occupants.

I concluded that a more fundamental cause was at stake in these attacks. It takes political commitment to require the military discipline needed so that the process works. After Palestinian paramedics were killed during the second Intifada that began in 2000, the Israeli political and military leadership tightened its procedures and committed to following them. For a time, they cut down on the shootings and deaths.

Over time, however, as politics in Israel moved ever to the right, leadership and discipline on safe evacuation eroded. Written rules of engagement designed for civilian protection were not followed in the field. Killings of paramedics were either not investigated or whitewashed, and continued from one conflict to the next.

Now, visceral and justified outrage at Hamas’ atrocities and taking of hostages has led to a declining commitment to conduct combat operations in accordance with the law. Israel’s denial of water, food, and fuel — all essential for life — into Gaza is a de facto repudiation of its duty to allow and facilitate rapid and unimpeded passage of humanitarian relief for civilians in need. Energy Minister Israel Katz publicly rejected one of the most fundamental premises of the Geneva Conventions: that violations by one side do not justify violations by the other. It is a rule that is emotionally difficult to accept but essential to avoid a downward spiral of horrors. He wrote on social media that Israel will allow no water to flow nor fuel to be transported to Gaza until hostages are released, “humanitarianism for humanitarianism,” a phrase that conveys that noncompliance with the law by Hamas will be met with noncompliance by Israel.

We have seen the results of taking this road. After the terrorist attacks of Sept. 11, 2001, the administration of George W. Bush adopted a policy of “taking the gloves off” and called the Geneva Conventions quaint. That stance led to torture of detainees at secret “black” sites and arrests of people in the United States for no reason other than that they were Muslims.

From the experience of the first week of this war, if Israeli tactics and its view of its obligations continue, Palestinians will surely experience more deprivation, suffering, and death.

Leonard Rubenstein is distinguished professor of the practice at the Johns Hopkins Bloomberg School of Public Health and author of “Perilous Medicine: The Struggle to Protect Health Care From the Violence of War.”