3 April 2024

A team of medical experts have assessed Israel’s destruction of Gaza’s hospitals, its motives and its consequences in this report in the Journal of Public Health and Emergency. Note that the report was submitted for publication on 18 January 2024. The situation is even more horrendous today.

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

Paola Manduca 1*, Alice Rothchild 2, Alan Meyers 3, Gianni Tognoni 4, Derek Summerfield 5, Andrea Balduzzi1*, Vincenzo Stefano Luisi 6, 7*, Bruno Cigliano 8*, Lucio Nitsch 8, Rachel Rubin 9, Ireo Bono 10*, Vittorio Agnoletto 11, Lia Balduzzi 12, Nozomi Takahashi 13, Roberto Raso 14*, Tiziana Traverso 15 (retired), Franco Camandona 16

1 Department of Earth, Environmental and Life Sciences (DISTAV), University of Genoa, Genova, Italy;  
2 Harvard Medical School, Boston, MA, USA;
3 Boston University School of Medicine, Boston, MA, USA;
4 Fondazione Lelio Basso, Rome, Italy;
5 Kings College, University of London, London, UK;
6 Department of Pediatric, Massa Hospital, Massa, Italy;
7 Palestine Children’s Relief Fund (PCRF)-Italia, Livorno, Italy;
8 Department of Pediatric, University of Naples Federico II, Naples, Italy;
9 Cook County Department of Public Health, Chicago, IL, USA;
10Department of Oncology, Private Clinic, Savona, Italy;
11 L-37 – Scienze Sociali Per La Cooperazione, Lo Sviluppo E La Pace, University of Milan, Milan, Italy;
General Practitioner National Health Service, Genoa, Italy;
13 Cell Death and Inflammation Lab, VIB-University of Ghent Center of Inflammation
Research, Ghent, Belgium;
14 Regional Epidemiology Reference Service for the Surveillance, Prevention and Control of Infectious Diseases, Local Health Unit of Alessandria, Alessandria, Italy;
15 Functional Rehabilitation Unit, Clinical Scientific Institute Maugeri, Genova, Italy;
16 Department of Gynecology, Galliera Hospital, Genoa, Italy
Correspondence to: Paola Manduca, PhD. Retired Professor Genetics, Department of Earth, Environmental and Life Sciences (DISTAV), University of Genoa, C. Europa 26, Genova 16132, Italy. Email: paolamanduca@gmail.com.
Received: 18 January 2024; Accepted: 18 March 2024; Published online: 25 March 2024.
doi: 10.21037/jphe-24-11

View this article at:

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

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
As professionals in health, and according to the

inherent duty to protect lives, we embrace the

urgent request of Gaza doctors

(I) To grant entry of medical supplies and fuel, adequate

to the needs;

(II) To allow medical international teams to support the

unsustainable workload;

(III) 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.



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/

Conflicts of Interest:
All authors have completed the
ICMJE uniform disclosure form (available at
The authors have no conflicts of interest to declare.

Ethical Statement:
The authors are accountable for all
aspects of the work in ensuring that questions related

to the accuracy or integrity of any part of the work are

appropriately investigated and resolved.

Open Access Statement:
This is an Open Access article
distributed in accordance with the Creative Commons

Attribution-NonCommercial-NoDerivs 4.0 International

License (CC BY-NC-ND 4.0), which permits the non-

commercial replication and distribution of the article with

the strict proviso that no changes or edits are made and the

original work is properly cited (including links to both the
formal publication through the relevant DOI and the licence).
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