Medical experts confirm Israel’s deliberate destruction of Gaza’s healthcare system
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 King’s 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;
12 General Practitioner National Health Service, Genoa, Italy;
12 General Practitioner National Health Service, Genoa, Italy;
13 Cell Death and Inflammation Lab, VIB-University of Ghent Center of Inflammation
Research, Ghent, Belgium;
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: https://dx.doi.org/10.21037/jphe-24-11
doi: 10.21037/jphe-24-11
View this article at: https://dx.doi.org/10.21037/jphe-24-11
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).
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
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.
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.
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
(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.
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
(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.
Acknowledgments
Funding: None.
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:
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.
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.
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.
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).
References
1. Hostilities in the Gaza Strip and Israel | Flash Update
#98. 2024. Available online: https://reliefweb.int/report/
occupied-palestinian-territory/hostilities-gaza-strip-
and-israel-flash-update-98-enarhe
2. Hostilities in the Gaza Strip and Israel | Flash Update
#96. 2024. Available online: https://reliefweb.int/report/
occupied-palestinian-territory/hostilities-gaza-strip-
and-israel-flash-update-96-enarhe
3. Mahase E. Gaza: Death toll rises to nearly 20 000 as attacks
on hospitals and staff continue. BMJ 2023;383:2973.
4. Gaza: Unlawful Israeli Hospital Strikes Worsen
Health Crisis. Available online: https://www.hrw.org/
news/2023/11/14/gaza-unlawful-israeli-hospital-
strikes-worsen-health-crisis
5. Baraquoni NA, Qouta SR, Vänskä M, et al. It Takes Time
to Unravel the Ecology of War in Gaza, Palestine: Long-
Term Changes in Maternal, Newborn and Toddlers’ Heavy
Metal Loads, and Infant and Toddler Developmental
Milestones in the Aftermath of the 2014 Military Attacks.
Int J Environ Res Public Health 2020;17:6698.
6. Hussein-Sabbah S. Pregnant women in Gaza face perilous
conditions as maternity services and infrastructure
crumble. BMJ 2023;383:2895.
7. Preventing famine and deadly disease outbreak in Gaza
requires faster, safer aid access and more supply routes.
2024. Available online: https://www.who.int/news/
item/15-01-2024-preventing-famine-and-deadly-
disease-outbreak-in-gaza-requires-faster–safer-aid-
access-and-more-supply-routes
8. Panel discussion on the Responsibility to Prevent
Genocide. Available online: https://www.un.org/
unispal/291591-2/
9. Application of the Convention on the Prevention and
Punishment of the Crime of Genocide in the Gaza Strip
(South Africa v. Israel). 2024. Available online: https://
www.icj-cij.org/sites/default/files/case-related/192/192-
20240112-pre-01-00-en.pdf
10. Protection of civilians. Available online: https://www.
unocha.org/protection-civ
1. Hostilities in the Gaza Strip and Israel | Flash Update
#98. 2024. Available online: https://reliefweb.int/report/
occupied-palestinian-territory/hostilities-gaza-strip-
and-israel-flash-update-98-enarhe
2. Hostilities in the Gaza Strip and Israel | Flash Update
#96. 2024. Available online: https://reliefweb.int/report/
occupied-palestinian-territory/hostilities-gaza-strip-
and-israel-flash-update-96-enarhe
3. Mahase E. Gaza: Death toll rises to nearly 20 000 as attacks
on hospitals and staff continue. BMJ 2023;383:2973.
4. Gaza: Unlawful Israeli Hospital Strikes Worsen
Health Crisis. Available online: https://www.hrw.org/
news/2023/11/14/gaza-unlawful-israeli-hospital-
strikes-worsen-health-crisis
5. Baraquoni NA, Qouta SR, Vänskä M, et al. It Takes Time
to Unravel the Ecology of War in Gaza, Palestine: Long-
Term Changes in Maternal, Newborn and Toddlers’ Heavy
Metal Loads, and Infant and Toddler Developmental
Milestones in the Aftermath of the 2014 Military Attacks.
Int J Environ Res Public Health 2020;17:6698.
6. Hussein-Sabbah S. Pregnant women in Gaza face perilous
conditions as maternity services and infrastructure
crumble. BMJ 2023;383:2895.
7. Preventing famine and deadly disease outbreak in Gaza
requires faster, safer aid access and more supply routes.
2024. Available online: https://www.who.int/news/
item/15-01-2024-preventing-famine-and-deadly-
disease-outbreak-in-gaza-requires-faster–safer-aid-
access-and-more-supply-routes
8. Panel discussion on the Responsibility to Prevent
Genocide. Available online: https://www.un.org/
unispal/291591-2/
9. Application of the Convention on the Prevention and
Punishment of the Crime of Genocide in the Gaza Strip
(South Africa v. Israel). 2024. Available online: https://
www.icj-cij.org/sites/default/files/case-related/192/192-
20240112-pre-01-00-en.pdf
10. Protection of civilians. Available online: https://www.
unocha.org/protection-civ