SCIENTIFIC LETTER

 

Israel's systematic weaponisation of health in Gaza

 

 

The Israeli army has been relentless in its targeting of healthcare workers and infrastructure in Gaza. This strategy is not new for the Zionist state, and the use of health as a weapon against the occupied Palestinian population has been previously documented over the years.^[1-4] While this is not a novel concept in modern day warfare, the scale at which it is being used to strangulate a population is unprecedented. Deliberate targeting of health infrastructure, manufactured scarcity of medical supplies and availability of fuel, and restricted access to basic necessities are all tactics employed to destroy healthcare as a weapon of war. Through these actions, Israel aims to amplify the scale of civilian losses in the Gaza strip and force survivors into exodus.

In Gaza specifically, the attacks against health infrastructure witnessed since 7 October 2023 are deeply rooted in Israel's history of weaponising health. Two separate World Health Organization (WHO) reports outline how fragmentation of the Palestinian people, implementation of a permit regime, physical obstacles to movement, and protection gaps have resulted in health inequities. These factors have created substantial barriers to healthcare provision and health access in the occupied West Bank, including east Jerusalem and the Gaza Strip.^[2,,3] According to Dr Richard Peeperkorn, WHO representative for the occupied Palestinian territory, 'The Palestinian health system suffers the consequences of longstanding displacement, refugeehood and occupation.'^[3] Prior to October 2023, healthcare systems in Gaza were already on the verge of collapse, with only 36 hospitals operating at full capacity and a total of 3 412 beds serving a population exceeding 2 million people.^[5] These figures indicate a maximum ratio of 1.55 hospital beds per 1 000 individuals across the entire region. Patients needing access to specialised treatment outside of Gaza have consistently been prevented from exiting. In 2021 alone, over 36% of requests for medical permits have either been declined or left unanswered by Israeli authorities,^[6] leading to preventable deaths among patients with urgent conditions.

In 2009, Amnesty International published a 120-page research paper titled 'Israel/Gaza: Operation Cast Lead: 22 Days of Death and Destruction'.^[1] Under the heading "Attacking and Obstructing Medical Workers'; the following conclusion was drawn: 'The Fourth Geneva Convention relative to the Protection of Civilian Persons in Time of War of 12 August 1949 obliges to respect and protect the wounded, to allow the removal from besieged areas of the wounded or sick, and the passage of medical personnel to such areas. The deliberate obstruction (by Israel) of medical personnel to prevent the wounded receiving medical attention constitutes "wilfully causing great suffering or serious injury to body or health" a grave breach of the Fourth Geneva Convention, and a war crime.'^[1] The report was based on witness accounts and reliable evidence.

In January 2024, the United Nations (UN) and UN Office for the Coordination of Humanitarian Affairs (OCHA) published statistics relating to the medical situation in Gaza due to Israel's ongoing aggression:^[7]

• 337 healthcare workers have been killed.

• 145 UN staff have been killed.

• 14 out of 36 hospitals in Gaza are only partially functional, and suffer from outages and major shortages of medical supplies.

• 26 out of 36 hospitals in Gaza are damaged.

• 122 ambulances have been damaged.

• 1.9 million Gaza residents are displaced.

The numbers are shocking, and the extent of damage is unfathomable, difficult to comprehend through figures alone.

By November 2023, all hospitals in Northern Gaza had become non-functional.^[8] It was at this point that Israel led armed invasions of hospitals, including the largest medical complex in the region, Al-Shifa, and the Indonesian Hospital, which at the time was the last remaining operational hospital in Northern Gaza.^[9] This demonstrates a sustained and orchestrated commitment by Israel to the destruction and evacuation of healthcare facilities. Despite claims made by the Israeli army that armed Palestinian groups have used health facilities for military purposes, Human Rights Watch^[10] have reported that no evidence has yet been presented that legally justifies the loss of the protected status of hospitals and other health infrastructure, as codified in International Humanitarian Law. An extensive investigation by the Washington Post^[11] of the Israeli attacks and invasion of AlShifa Hospital found that there was insufficient evidence to support Israel's claims of the hospital being used as a command and control centre, or was connected to a larger tunnel network. Importantly, the burden of proof remains with the attacker to provide adequate evidence of the loss of protected status of a health facility; 'in case of doubt, there should be a presumption of civilian status'.^[12] Nevertheless, if a health facility loses its protected status, the principles of proportionality, precaution and distinction still apply.^[12] Despite these succinct international laws, the destruction of the healthcare system has been the main thrust of the Israeli military strategy."^[13]

Human Rights Watch has verified footage of Israel's use of white phosphorus munitions in Gaza and Lebanon, actions which may constitute war crimes. Despite this verification, the Israeli military has denied use of such chemical weapons.^[14] On the evening of 17 October, a missile strike at Al-Ahli Hospital in Gaza City killed at least 471 people. The hospital was operational and treating patients at the time, while internally displaced people had sought shelter close to the facility.^[15] The Al-Ahli Hospital missile strike represents one of the most horrific incidents at a healthcare facility in our collective history.

The repeated patterns of these attacks indicate that the damages inflicted on Gaza's already precarious health system and the systematic murder of medical staff are part of a broader strategy seeking to weaponise healthcare. Beyond overt destruction, UNICEF released a report this week documenting the broader health-related impacts suffered by the civilian Gaza population.^[16] These include:

• High levels of displacement and overcrowding in collective centers and scattered sites in the Gaza Strip persist, with extremely challenging hygiene and sanitation conditions. On average, 340 individuals share one toilet, and 1 290 persons share one shower.

• The babies of 5 500 women due to give birth in the next month in the Gaza Strip are at risk of dying, as their mothers do not have access to prenatal or postnatal check-ups due to the bombings and the need to flee for safety. Anxiety is also leading to premature births, as reported by UNFPA.

• Over 90% of children aged between 6 and 23 months and pregnant, breastfeeding women face severe food poverty, with access to two or fewer food groups per day.

In addition to the above, the withdrawal of fuel and power sources^[17] and the closure of all humanitarian corridors for the delivery of aid have created the perfect storm for the outbreak of multiple epidemics. Cases of scabies, lice, chickenpox, skin rash, hepatitis A,^[18] and upper respiratory infections have been reportedly rising, in a context of disrupted vaccination campaigns and disease surveillance systems.

The weaponisation of health negates the right to exist and resist. It is a means of collectively punishing a population and discouraging or deterring any form of resistance, whether peaceful or violent. However, the disproportionate attacks against a civilian population not only violates the basic tenets of international humanitarian law, but also perpetuates structural power imbalances rooted in the asymmetry between the coloniser and the colonised. By instilling fear, physical and psychological trauma, the weaponisation of health is instrumental to forcibly displace Palestinians, by means of rendering Gaza inhabitable and hostile. Any credible commitment to -and movement for- health justice must acknowledge both the ongoing and long-standing violence against healthcare workers and attacks against healthcare in this context as an extension of the systematic campaign of violence and oppression against the Palestinian people. As South African healthcare workers, me cannot allow Israel to continue to perpetuate this and must join the call of millions around the world demanding justice.^[19]

A Soni

MB BCh, Dip PEC, DA, FC Neurol, MMed

Neuroscience Institute, University of Cape Town, South Africa; Medical volunteer with the Gift of the Givers

ajsoni008@gmail.com

 

References

1. Amnesty International. "Operation Cast Lead": 22 Days of Death and Destruction. United Kingdom: Amnesty International Publications, 2009. https://www.amnesty.org/en/wp-content/uploads/2021/06/mde150152009en.pdf

2. World Health Organization. Right to Health: Barriers to Health and Attacks on Health Care in the Occupied Palestinian Territory, 2019 to 2021. Cairo: WHO Regional Office for the Eastern Mediterranean, 2022.         [ Links ]

3. World Health Organization. Palestinian Voices, 2022-2023. Cairo: WHO Regional Office for the Eastern Mediterranean, 2023.         [ Links ]

4. Human Rights Watch. A Threshold Crossed: Israeli Authorities and the Crimes of Apartheid and Persecution. United States: Human Rights Watch Publications, 2021.         [ Links ]

5. Palestinian Ministry of Health. 2022 annual report, southern governorates Gaza Strip, May 2023. https://www.moh.gov.ps/portal.

6. Al Mezan Center for Human Rights. Delayed, Denied and Deprived: The Collective Punishment of Palestinian Patients in Gaza in the Context of Israel's 15-year Blockade, June 2022.

7. United Nations Office for the Coordination of Humanitarian Affairs. Humanitarian Crisis Unveiled: Healthcare Under Attack in Gaza - Joint Statement by the Syrian American Medical Society (SAMS), and the Palestinian American Medical Society (PAMA), February 2024.

8. Al Jazeera. Hospitals in northern Gaza completely out of service: Health official. November 2023. (x March 2024)

9. Middle East Eye. Israel-Palestine war: Indonesian Hospital in Gaza besieged as reports of ceasefire denied. November 2023.

10. Human Rights Watch. Gaza: unlawful Israeli hospital strikes worsen health crisis. 2023. https://www.hrw.org/news/2023/11/14/gaza-unlawfulisraeli-hospital-strikes-worsen-health-crisis. (x March 2024)

11. Loveluck L, Hill E, Baran J, et al. The case of al-Shifa: investigating the assault on Gaza's largest hospital. 2023. https://www.washingtonpost.com/world/2023/12/21/al-shifa-hospital-gaza-hamas-israel/ (x March 2024)

12. Hakki L, Stover E, Haar RJ. Breaking the silence: advocacy and accountability for attacks on hospitals in armed conflict. International Review of the Red Cross; 2022. https://internationalreview.icrc.org/articles/breaking-the-silence-advocacy-and-accountability-forattacks-on-hospitals-in-armed-conflict-915. (x March 2024)

13. Al Jazeera. Surgeon says Israel strategically destroying Gaza health system. 2023. https://x.com/AJEnglish/status/1726725025607148017. (x March 2024)

14. Wintour P. Israel denies using white phosphorus munitions in Gaza. 2023. https://www.theguardian.com/world/2023/oct/13/israelmilitary-white-phosphorus-gaza-lebanon. (x March 2024)

15. PRCS report update. From Saturday, October 7, 2023, at 06:00 AM until Wednesday, October 18, 2023, at 14:00. Ramallah, Palestine Palestinian Red Crescent Society; 2023.

16. United Nations Office for the Coordination of Humanitarian Affairs. UNICEF State of Palestine Humanitarian Situation Report No. 19 (Escalation): 15 to 28 February 2024. March 2024.

17. The Wall Street Journal. Gaza Hospitals, Shelters Cut Back on Services as Fuel Runs Short. October 2023.

18. Reuters. WHO says Gaza's health system must be protected as disease spreads. November 2023.

19. Smith J, Kwong EJL, Hanbali L et al. Violence in Palestine demands immediate resolution of its settler colonial root causes. British Medical Journal Global Health; November 2023.

 

 

Accepted 11 March 2024