The face of the ongoing onslaught on Gaza has no doubt been Dr. Hammam Alloh, the thirty-six-year-old Palestinian nephrologist at northern Gaza’s Al-Shifa Hospital who refused to evacuate it when it was invaded by Israeli troops. “And if I go, who treats my patients?” he said in an October 31 interview. “We are not animals. We have the right to receive proper healthcare,” he added. Two weeks later, Alloh was killed by an Israeli airstrike, along with his father, brother-in-law, and father-in-law.
Alloh’s use of the word “animals” was certainly not lost on viewers. Israeli Defense Minister Yoav Gallant had used that same language on October 9 when he announced a “complete siege” on Gaza, labeling its residents as “human animals.” Hamas’s attacks on October 7 would predictably generate a violent military reaction from Israel. But this Israeli campaign in Gaza, a strip of land where more than 80 percent of its population lived in poverty even before October 7, has been of a different character entirely than any previous ones. This onslaught has featured direct attacks on hospitals and the intentional undermining of the entire health care system: shelling, the killing and arresting of health care personnel, the direct and indirect killing of hundreds of patients, underprovision or complete lack of proper medical care, and unwarranted suffering for thousands of patients due to shortages in basic medications, water, food, and fuel. The attacks have made clear that the repression of Palestinian rights now has a new feature: the systematic destruction of the very institutions that sustain life.
At the time of this writing, the World Health Organization (WHO) has recorded about 500 attacks on health care in the occupied Palestinian territory in 70 days—an average of a little more than 7 attacks per day. This includes attacks on health care facilities, personnel, ambulances, patients, warehouses, and supplies. The Union of Medical Care and Relief Organizations recently reported that 283 health care workers have been killed in Gaza so far. Some have been shot directly; others have been killed during hospital attacks. Doctors Without Bordors/Médecins Sans Frontières (MSF) itself has lost several of its doctors in direct attacks on either convoys or hospitals. Palestinian medical staff—including many consultant physicians at Gaza’s major hospitals—have reportedly been abducted or detained by Israeli forces (A group called Healthcare Workers Watch-Palestine has tracked over 116 such cases).
The most prominent detainee is the director of Al-Shifa hospital, Muhamad Abu Salmiya, who was arrested on November 23 while evacuating with a WHO convoy (and who remains in custody). His appeal to the global medical community to “condemn the acts against medical professionals” was published in The Lancet a few days later. But many major U.S. medical journals and associations have been hesitant to heed his call. When the American Medical Association (AMA) met in mid-November to draft a call for a ceasefire and the protection of civilians and medical professionals, the effort was shut down. But in 2022 the AMA published a call for an immediate ceasefire in Ukraine—and didn’t mince words. “The AMA is outraged by the senseless injury and death the Russian army has inflicted on the Ukrainian people,” the AMA president said. “For those who survive these unprovoked attacks, the physical, emotional, and psychological health of Ukrainians will be felt for years.” And while in a November 9 statement the AMA said that it “supports efforts to deliver humanitarian aid and medical supplies to those facing a humanitarian crisis” (note the anonymous “those”), no mention has been made of the unfolding “public health catastrophe” in Gaza that the WHO has been warning about.
Perhaps the most astounding silence has come from the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry. Both released prompt statements in October condemning the “recent attacks and acts of terror in Israel,” but have kept silent regarding the tremendous psychological trauma that decades of occupation, and now indiscriminate bombardment, have unleashed on Gaza’s children and adolescents. How can one comprehend this dissonance if not in terms of a double standard?
Some groups have risen to the moment. The American Public Health Association (APHA), the largest and oldest public health association in the United States, took the lead to call for an immediate ceasefire in the Gaza Strip on November 15. MSF and some other NGOs, like Physicians for Human Rights-Israel, have also called for ceasefires. The American Psychological Association was more balanced in its statement, recognizing that “all individuals deserve to live free of fear and violence so that their mental health and well-being can flourish.”
Yet without a broader effort from the medical community, these calls will register as little more than blips on the radar. The destruction of health care in Gaza has triggered alarms about the undermining of the Geneva Conventions, the core of the international law that aims to protect the lives of civilians and their vital infrastructures, like schools and hospitals. In the face of Israel’s broad disregard for these laws, medical professionals might be some of the most crucial dissenting voices against Israel’s mission to render Gaza unlivable.
Even before the IDF’s ground operations began on October 27, Gaza’s main hospitals, concentrated in the north of the strip, had been the target of indiscriminate attacks and bombardments, including the deliberate use of white phosphorus artillery shells. White phosphorus, banned under international law, is a substance that inflicts horrific skin burns that are difficult to heal or treat in conflict-ridden areas; it damages vital organs causing lifelong injuries (physical and psychological) and triggers extensive fires.
Then the IDF began warning Gaza’s main hospitals—including Al-Shifa (Arabic for “healing,” ironically), the largest hospital and refugee camp—to immediately evacuate. Tedros Ghebreyesus, director of the WHO, repeatedly decried that it was impossible to evacuate hospitals without endangering the lives of thousands of patients, including many in critical condition. For days the world waited anxiously for evidence proving Israel’s claim that Al-Shifa Hospital was a cover for tunnels below it that housed the “command center” of Hamas. In the meantime, Netanyahu’s government, armed with the backing of the United States and the European Union, proceeded with an attack that the WHO condemned as “totally unacceptable” and that all major humanitarian organizations denounced as “a violation of International Humanitarian and Human Rights Law and Conventions.” The military operation, which took shape in only a few days, consisted of advancing tanks, bombing, and forced evacuation with no safe route and no ambulances for the thousands of patients and refugees who sought shelter at the hospital.
The Biden administration had hoped the operation would be “targeted” and “precise.” As it turned out, it was neither. And after several failed attempts, the only evidence the IDF managed to provide consisted of a few weapons and some tunnels with no clear military purpose—but no command center.
The product of the Al-Shifa debacle was only widespread death, destruction, and misery. A WHO delegation described Gaza’s main hospital as a “death zone.” They were shocked by what they saw: a mass grave at the entrance of the hospital, only 25 staff left to care for 291 seriously ill patients, premature babies in “extremely critical conditions,” no water, no food, no medical supplies, and no fuel. Patients’ wounds were festering due to an acute shortage of antibiotics. About 2,500 patients—among them many sick and injured, including amputees—were ordered to evacuate south, walking through an apocalyptic landscape of ruined streets and rotting corpses. The hospital has yet to recover: a recent December delegation to Al-Shifa described it as a “bloodbath” and a “hospital in need of resuscitation.”
That the dismantling of Al-Shifa Hospital did not seem to achieve any military objective against Hamas suggests that it is part of a broader strategy: the strategic obliteration of Gaza’s health care system. The Al-Shifa attack was no isolated incident. In November the Al-Rantisi Specialized Hospital for Children, Gaza’s only medical center with a pediatric cancer ward, had to evacuate under catastrophic circumstances after heavy bombing. Nearby, the only psychiatric hospital in Gaza was destroyed at a time when psychosocial support services and mental health support are perhaps more urgent than ever. The Turkish-Palestinian Hospital, the only hospital dedicated to cancer, ran out of fuel and could no longer function. The International Eye Hospital was reduced to rubble. According to the WHO, an Israeli raid on Gaza’s Indonesian Hospital killed several patients and their companions and injured tens of people. When the fourth floor of the hospital was directly targeted with a missile, the solar panels that provided electricity were cut off. The IDF proceeded by shooting patients, interrogating them, and beating a nurse. The hospital is now in ruins and out of service. The October 25 decimation of the Centre for the Rehabilitation of the Disabled is laden with disturbing symbolism.
On December 12 Kamal Adwan Hospital, the only remaining functional hospital in the north of the strip, was put under siege for several days, then bombarded. Its inner courtyard was bulldozed, with allegedly dozens of patients buried under the rubble; its medical staff were stripped and detained (the hospital’s director, Ahmed Kahlot, remains in detention).
As a result of Israel’s onslaught, more than 70 percent of Gaza’s 36 hospitals are now out of service, according to the WHO. The UN has described the current health care situation as a “humanitarian disaster zone.” As of this writing, more than 20,000 Palestinians have been killed (not counting the thousands of bodies still buried under the rubble) and more than 50,000 have been injured. The numbers, likely an underestimate according to U.S. officials, include more than 10,000 children and 4,000 women, who amount to about 70 percent of the casualties. According to the NGO Save the Children, more children have been killed in Gaza than in all of the world’s conflicts combined in each of the past three years. Overall, thousands have sustained serious injuries, and over 1.8 million people have been displaced. Thousands of pregnant women lack adequate care, and dozens of premature babies have their lives hanging in balance, not to mention the thousands of chronic patients suffering from the acute shortage of essential medications and life-saving equipment.
Lacking painkillers and sometimes light, surgeons have reported horrific procedures in which they must amputate children’s limbs and dress burns with no anesthetics, using vinegar in lieu of antiseptics, the light of their cell phone screens to see, and ketamine to knock out patients before operating on them. Such circumstances have made two chief tenets of modern medical practice—“standard of care” (the generally accepted procedures that medical professionals are expected to follow when treating patients with certain conditions) and “continuity of care” (the ability to follow up with patients)—not only unsustainable but devoid of any meaning.
On Tuesday UN officials reported that the Nasser hospital, the largest hospital still functioning in Gaza, had been shelled twice in the last two days, stretching an already barely functioning facility to its limits. The victims of Israeli hospital bombings, said a UN spokesperson, now include children recovering from amputations suffered from past bombings.
The situation is so dire that MSF, which typically remains politically neutral, has taken the unusual stance of calling for a ceasefire. The UN secretary-general António Guterres declared that Gaza is in the midst of an “epic humanitarian catastrophe.” The damage to water and sanitation infrastructure, overcrowded shelters, the unburied corpses under the rubble, the deterioration of sanitary conditions, and dwindling access to adequate health care are all contributing to the quick and lethal spread of disease. The number of gastrointestinal and infectious diseases (meningitis, chickenpox, and hepatitis A) have surged in recent days to the extent that Israelis are now concerned that cholera will endanger the health of the hostages and themselves. The WHO has warned that people will now die from diseases and lack of health care than from bombardment.
In earlier centuries, colonizers weaponized contagious diseases, like smallpox or the plague, to decimate native populations. This continues to be used as a strategy of war. It has been even contemplated as an extermination strategy in Gaza. Last month Israeli Finance Minister Bezalel Smotrich endorsed the genocidal language of the retired Israeli general Giora Eiland, who in a column in the Hebrew-language newspaper Yedioth Ahronoth called for causing the spread of epidemics as a way of achieving Israel’s goals in its ongoing campaign. The collapse of the health care system should make us wonder if this is not already happening on the ground in Gaza.
For Agnès Callamard, Amnesty International’s secretary general, “What’s happening in Gaza is a litany of violations of international law … not seen since World War II.” Whether or not these acts “verge of genocide” or constitute genocide, as many prominent historians and legal scholars have argued, it should be seen as part of a broader campaign of depopulation and rendering Gaza uninhabitable.
More than a decade ago, a group of 50 international aid agencies, including the WHO, Human Rights Watch and Oxfam, called on Israel to lift its illegal and inhumane siege and blockade of Gaza, to no avail. In a 2010 intervention in the House of Commons, David Cameron the then British Prime Minister had even described Gaza as an “open prison.” The inmates of that prison—1.6 million civilians at the time—were kept alive on a minimum caloric diet calculated rationally and meticulously by Israeli authorities to cause malnutrition without causing outright starvation. The latest operations of the long siege of Gaza, especially the decision to cut off water, fuel, medicines and food, while relentlessly and indiscriminately bombing it, goes still further. The starvation of civilians as a method of war is a crime prohibited by the Geneva Conventions and the Rome Statute. By bombing Gaza’s last operational wheat mill and restricting access to humanitarian aid, the UN has warned that these deliberate destructions “threaten to make the continuation of Palestinian life in Gaza impossible.” But it also suggests that Israel has embraced a common war tactic of rogue states such as Syria or Russia.
And like any rogue state, Israel has showed little hesitance to flout international law—including the Geneva Conventions, the foundation of International Humanitarian Law, which regulates the conduct of armed conflict and above all seeks to limit its impact.
The carnage of the Battle of Solferino in 1859 served as the catalyst for an international conference in Geneva laying the groundwork for the First Geneva Convention and the establishment of the International Committee of the Red Cross (ICRC). Formally known as the “Geneva Convention for the Amelioration of the Condition of the Wounded in Armies in the Field,” the Convention’s hope was that in wartime, belligerents would declare lazarettos and field hospitals “neutral,” and that similar protection would be extended to army medical staff, voluntary helpers, and wounded soldiers. To mark the persons and objects to be protected, governments would choose a common, distinctive sign: the Red Cross, or, in majority-Muslim countries, the Red Crescent (adopted on the request of the Ottoman Empire).
The First Geneva Convention included provisions for military hospitals but not civilian ones. At the time, wars were primarily fought on the battlefield where armies confronted each other. But after the invention of warplanes, civilian and military hospitals were more frequently and more viciously targeted. During World War I, Germany bombed London hospitals and Great Britain reciprocated. In the mid-1930s, many Red Cross and Red Crescent field hospitals caring for sick and wounded Ethiopian soldiers were attacked by Mussolini’s air force. While the 1907 Hague Conventions contained some provisions on the protection of civilian hospitals, they were first mentioned explicitly only in the Fourth Geneva Convention, whose articles were adopted in 1949. It is worth noting that it was the indiscriminate Allied bombing of German hospitals during World War II, as well as the United States’ dropping of napalm-filled bombs on Tokyo and the nuclear bombing of Hiroshima and Nagasaki, that prompted international legislation on the protection of civilian infrastructures, including hospitals.
The Fourth Geneva Convention is very clear: hospitals and medical staff are protected as long as they do not “commit, outside their humanitarian duties, acts harmful to the enemy.” Article 15 in specific mentions hospitals as “neutralized zones intended to shelter from the effects of war the following persons, without distinction: (a) wounded and sick combatants or non-combatants; (b) civilian persons who take no part in hostilities, and who, while they reside in the zones, perform no work of a military character.” Yet despite the Fourth Convention’s additional amendments, transgressions against the “neutrality” and sanctity of hospitals have continued to occur—which resulted in two additional protocols in 1977 designed to strengthen protections for civilians and those in need of medical care.
And even if hospitals are used for military purposes, there are rules to be followed. According to the Chief Prosecutor at the International Criminal Court (ICC) Karim Khan, the onus is on those who fire the gun to provide the evidence before attacking. Moreover, “precautions must be taken, including effective warnings, which consider the ability of patients, medical staff, and other civilians to evacuate safely.” None of these were followed at Al-Shifa or other hospitals that were targeted.
Have we gone backward? Any a priori endorsement or encouragement of indiscriminate attacks on civilian health infrastructures, like the disturbing open letter signed by 100 Israeli physicians in support of bombing hospitals presumed to be “terrorist nests,” is a regression to a pre-World War II status quo where lex talionis—the law of retaliation—rather than human rights, was the rule. Doctors’ embrace of violence against civilians is a deliberate violation of the principle of “medical neutrality” and a show of contempt for the Hippocratic oath of “doing no harm.”
In 1998 the Rome Statute, which was adopted and ratified in 2002, created the ICC, providing it with a permanent authority to prosecute individuals for international crimes, including genocide, crimes against humanity, war crimes, and the crime of aggression. Article 8 of the Statute specifically names “hospitals and places where the sick and wounded are collected” as sites which cannot be intentionally attacked. The ICC’s goal is to help end impunity for the perpetrators of these kinds of crimes. Some of the most notable non-ratifying states include the United States, Russia, India, China, Iran, and Israel. Palestine, however, is Party to the Rome Statute and as such, the ICC prosecutor can initiate investigations into alleged crimes falling under the court’s jurisdiction. Both Israel and the United States, nevertheless, are full signatories of the Geneva Conventions.
Hamas’s brutal attack on Israel that killed hundreds of civilians and led to the kidnapping of 240 hostages and alleged sexual atrocities are violations of the Geneva Conventions, of course. The ICC chief prosecutor has vowed to hold both Hamas and Israel accountable. But he failed to mention the systematic and unprecedented nature of Israel’s attacks on hospitals and health care professionals. Whether these crimes will be investigated in courts of international law remains to be seen.
Such crimes are part of a larger pattern. For while Israel has surpassed other countries in terms of the scale, intensity, and lethality of its health care attacks, it is not the only culprit. In recent years, attacks on health care facilities across the world have intensified in scale and frequency. In 2021-2022 alone, there were about 2,500 confirmed attacks on health care, according to the WHO: a 25-fold increase from 2015–2016. This year is set to see the highest ever recorded number of health care attacks since the WHO started compiling the data in 2014. More worrisomely, hospitals and health care infrastructures are increasingly attacked to threaten and demoralize civilian populations. Now, not only are health care facilities no longer considered “neutral” by the belligerents, but they have also become targets for strategic military purposes, and—perhaps more strikingly—their ruins are used as a deterrence against any act of civil resistance or defiance.
Long before Russia’s targeted bombing of health care facilities in Ukraine in 2022, MSF frequently reported the deliberate targeting of its clinics and hospitals in Afghanistan, Syria, Gaza, and Yemen. The Syrian regime and its Russian ally have perfected their ruthless attacks on physicians, hospitals, and clinics, killing, destroying, and pulverizing health care personnel and facilities as a way to punish and deter civilian populations. While Russia has been the worst offender, if we compare the number of attacks on health care by population, Israel far surpasses all other countries. What should alarm us above all is how normal the weaponization of hospitals has become, and—with the silence of professional medical associations—how medicine has been misused as technologies of “not only death but grotesque and premature death” to borrow psychiatrist Robert Jay Lifton’s characterization of the effects of nuclear weapons.
The time has come to critically assess the failure of the Geneva Conventions to protect civilians and civilian infrastructures, especially hospitals. What explains this shift from a time when the rules of law were respected to some extent that marked the post-World War II era to a time when they are entirely dismissed?
Three interrelated elements seem to explain this trend. First is the increasing lethality of modern weapons. Second is the increasing inequality and inequity between lives judged valuable and worth salvaging and protecting at any cost and others treated as cheaply disposable. Recent conflicts in occupied Palestine, Syria, Iraq, Sudan, Yemen, or Ukraine, and especially the Covid-19 pandemic, have unveiled great disparities in the way in which life itself is valued. And the third has to do with a new post-9/11 world order—or rather disorder—where “might is right” has redefined international relations and created a world where the rule of international law applies to some, but not all, countries.
In the aftermath of World War I, many prominent intellectuals abandoned their commitment to universal values in favor of partisan interests. The French philosopher Julien Benda called this desertion “the treason of the clerks” (La trahision des intellectuels), with “clerks” here referring to the medieval definition of a scribe or a member of the intelligentsia. They had become ideologues, he argued, abandoning their role as independent thinkers and defenders of higher universal values. What we are witnessing today is another betrayal: this time by what could be called medical clerks, whose commitment should be first and foremost to the “art of healing.” In these times of crisis, medical doctors must refuse to be blinded by ideology and partisanship. Those who have remained silent in the face of the destruction of human life in Gaza would do well to remember the basic Hippocratic principle: “to use my power to help the sick to the best of my ability and judgment.”