Just over a year ago, after a massive explosion in the parking area of Al-Ahli Arab Hospital in Gaza killed 471 people and wounded hundreds more, plastic and reconstructive surgeon Dr. Ghassan Abu-Sittah, who was performing surgery at Al-Ahli when the roof fell in, gave an extraordinary press conference. Flanked by fellow health care workers in their scrubs and surrounded by white-shrouded dead bodies in the hospital courtyard, Abu-Sittah, a British-Palestinian volunteer in Gaza with Doctors Without Borders, described how people came to the hospital in search of safety.

“This is a war crime that the world has seen coming,” he declared. “Israel has been warning the entire world that it was going to attack Palestinian hospitals, and it did exactly that.”

While Israel has denied responsibility for that specific attack, whose origin is still debated, since then, Israeli forces have directly attacked hospitals and other health care facilities dozens and dozens of times.

In a recently-released investigation that was presented to the United Nations General Assembly on Oct. 30, the U.N.-mandated independent Commission of Inquiry found that Israel has implemented a concerted policy to destroy the health care system in Gaza, and that it has committed the crime against humanity of “extermination.”

Salon previously reported the findings of the COI, which covers allegations from all sides in the region from Oct. 7, 2023, through the end of July 2024, and explored how they relate to the ongoing impact of Israel’s continued and intensifying operations in Gaza on health care facilities, staff and patients, an impact documented by other organizations. These include a report on the killing, detention and torture of health care workers released this month by Healthcare Workers Watch, a correspondence published last week in the Lancet documenting a surge in preventable maternal and neonatal deaths in Gaza, and a new report from the U.N. Special Rapporteur on the situation of human rights in the Palestinian territories occupied since 1967, Francesca Albanese, that addresses the worsening humanitarian crisis in Gaza.

While the evidence of Israel’s repeated and deliberate attacks on health care infrastructure has been presented to the world, many health care professionals and their patients have asked the international community why their calls for intervention are being ignored — and wonder where the solidarity is with health care workers in Gaza.

Distribution of medical aid and medicines to Nasser Medical Hospital in the city of Khan Yunis, south of the Gaza Strip, which recently arrived through the Rafah crossing on October 29, 2023 in Khan Yunis, Gaza. (Ahmad Hasaballah/Getty Images)“Nothing in this war makes sense, the entirety of it is unimaginable! I hope it ends soon, but no one seems to be trying to stop it,” Dr. S., a physician who worked in a north Gaza hospital until he and his family were displaced and the hospital was later attacked, raided and put out of service, wrote to Salon in a series of text messages. (Salon has agreed to protect his identity.) Dr. S. was trapped in Gaza when he returned home days before Oct. 7, 2023, to celebrate his graduation with family members he hadn’t seen during 10 years of medical studies abroad. He has lost 72 family members to Israel's attacks.

“In the midst of the devastating conflict in Gaza, doctors and medical staff are caught in an unimaginable crisis,” S. said. “The health care system, which should be a sanctuary in times of war, has instead become a target. Hospitals are under siege, and medical professionals, who are doing everything in their power to save lives, are under direct threat. Doctors are being attacked, kidnapped and killed, while the very institutions meant to provide care are being bombarded. Yet, the world remains largely silent on their plight. While there is global outrage over civilian casualties, the relentless attacks on the medical community remain underreported.”

War crimes the world has seen coming

On Nov. 8, 2023, another unique press conference took place in Gaza. This time it was at Al-Shifa Hospital, then the largest in the Gaza Strip. Standing outside the hospital, Palestinian children called on the world to prevent their deaths. The first young speaker stated in English, “We come to Al-Shifa Hospital to keep us from bombing. We suddenly run out of death more [sic] after bombing the hospital.”

On Nov. 11, the IDF laid complete siege to Al-Shifa Hospital, claiming that Hamas used it as a command and control center.

By Nov. 12, the World Health Organization, UNFPA and UNICEF’s regional directors jointly called for international action to put a halt to Israel’s attacks on hospitals, reporting that 137 attacks on health care infrastructure had already resulted in 521 deaths, including those of 16 medical workers. The attacks described in the COI report and documented since the period studied there by others, like Healthcare Workers Watch, Forensic Architecture, Human Rights Watch, other U.N. bodies and numerous media organizations, don’t just include hospitals. They also involve ambulances, which health care staff rely on to save the lives of people too badly injured to get to a hospital on their own. As the report states:

As at 15 July, 113 ambulances had been attacked and at least 61 had been damaged. The Commission documented direct attacks on medical convoys operated by the International Committee of the Red Cross (ICRC), the United Nations, the Palestine Red Crescent Society and non-governmental organizations. Access was also reduced owing to closure of areas by Israeli security forces, delays in coordination of safe routes, checkpoints, searches or destruction of roads.

The U.N. commission devoted special attention in its report to particularly egregious allegations, one of which was the story of five-year-old Hind Rajab and her family, and the paramedics who tried to save her life.

On Jan. 29, a car carrying Hind and her cousin, 15-year-old Leyan Hamada, as well as Hind’s aunt and uncle and three other cousins, was attacked by Israel Defense Forces while trying to evacuate from an area under heavy bombardment. After the adults in the car were killed, Leyan tried to call for help and got through to the Palestinian Red Crescent Society.

“They are shooting at us. The tank is right next to me. We're in the car, the tank is right next to us,” she told the PRCS dispatchers before they heard her screams and the sound of machine gun fire. When the dispatchers called back, Hind answered and told them her cousin was dead.

The little girl was trapped alone in the car for hours after that, using her cousin’s phone to beg PRCS staff for rescue, telling them, “I'm so scared, please come. Come take me. Please, will you come?" As described in the U.N. commission report, the dispatchers contacted the MOH and Israeli security forces to coordinate, over hours of negotiation, a designated safe route they might take to rescue the child — which is standard practice in conflict situations — and when finally given the green light, dispatched an ambulance with two paramedics.

When the ambulance was roughly 50 meters from the family’s car, it was struck by a tank shell. Twelve days later, after the Israeli military finally withdrew from the area, the family members’ bodies, including Hind’s, were retrieved from the bullet-ridden car. The ambulance was also found nearby, totally destroyed and with human remains inside.  

“The number of bullet holes in the car indicates [it] was being deliberately fired upon,” Chris Sidoti, one of the three members of the independent COI, told Salon in a video interview, citing “hundreds of bullet holes.” The condition of the ambulance suggested it had been struck by a tank shell, Sidoti continued, adding, “Hamas and Palestinian Islamic Jihad do not have tanks.”

Sidoti is a lawyer, consultant and expert in human rights law, institutions and mechanisms, and previously served as a Member of the U.N. Independent International Fact Finding Mission on Myanmar. The IDF has “denied there were any operational units in the area,” Sidoti said. “We do not accept that. We have evidence, and we have indicated, that the 162nd Brigade of the battalion was operating militarily in the area.”

The relevance of this episode for the U.N. commission’s report, Sidoti continued, is that health facilities, patients and personnel were involved. “The ambulance went there, the ambulance was attacked and the two paramedics were killed,” Sidoti said, and the fact that happened after “many hours of a child on the phone pleading to be rescued made it even more outrageous. Speaking personally, rather than officially, it’s what happens to kids that really gets me.”

The questionable legality of Israel’s attacks on health care

Attacks were widespread and systematic, starting in the north of the Gaza Strip (October to December 2023) and then later occurring in the centre (December 2023 to January 2024), the south (January to March 2024) and other areas (April to June 2024). The stated justification of the Israeli security forces for the attacks was that Hamas was using hospitals for military purposes, including as command-and-control centres.

Is it actually legal to bomb a hospital? Or, for that matter, to bomb 36 hospitals? 

At the presentation of the first part of the report to the U.N. Human Rights Council in June, COI chair Navi Pillay made clear that Israel has the right to protect its citizens from violence by Palestinian armed groups — but also that it must comply with international law while doing so. Hamas and Palestinian armed groups are likewise bound by international law. That includes law relating to health facilities in war, as codified in the First and Fourth Geneva Conventions as well as in “state practice” and the military manuals of most states.

“There are two dimensions to this,” Sidoti told Salon. Hospitals and health facilities are, he said, protected property. “That means that they cannot be attacked, but they can lose their protection only insofar as they are being used for military purposes, and any military action that is then taken in relation to the hospital is subject to the normal rules of combat,” meaning, most importantly, a “distinction between civilians and non-civilians.” Any military action must be “reasonable and necessary,” as well as “proportionate to the military usage that is occurring.”

In response to Salon’s request for comment, the IDF cited a social media statement: “Hamas’ use of medical facilities to conceal its operatives, to store its arsenal, to conduct attacks, to hide hostages, and to connect the sites of its terrorist activity through tunnels is clear as day. The evidence is overwhelming, yet, the COI chooses once again to turn a blind eye to Hamas’ strategy of abusing civilian infrastructure and using the Palestinian population as human shields.”

Does that mean that if Al-Qassam fighters (members of Hamas’ military wing) are hiding in a hospital, it’s OK to bomb them? Is it legal, in a conflict situation, to kill a human shield?

Sidoti offered an example, referring to the standards of reasonableness, necessity and proportionality mentioned above: “When Israeli authorities say they have found three armed terrorists in a hospital, that is not sufficient to justify the total destruction of a hospital, killing hundreds of people.”

Before Al-Shifa Hospital was besieged and attacked, for example, “the IDF produced this very flamboyant imagery of the command and control center underneath the hospital,” Sidoti said, “which they alleged form the basis of the justification of the attack. Yet none of the footage produced after the event indicated anything like that kind of command and control center underneath the hospital.”

He noted that there is some dispute among Israeli leadership as to whether tunnels found near or under the hospital were the work of Hamas, or had been constructed by Israeli authorities in the 1980s for storage purposes. “You need to have better evidence than that before you destroy an entire hospital complex and attack a hospital and kill large numbers of civilians,” Sidoti said. 

Facilities organized for medical purposes are protected under the Geneva Conventions, Additional Protocols and other law and practice — rules developed in part as a response to the horrors of the Holocaust revealed at the Nuremberg trials — and can be either civilian or military, permanent or temporary, fixed or mobile. They can therefore range from hospitals to ambulances to an outdoor vaccination clinic to a pharmaceutical storage facility in a medical clinic. At least 40,000 Palestinian deaths have occurred due to Israeli military action in Gaza (though an estimate published in the Lancet in July suggests the tally is closer to 200,000), even as billions and billions of dollars in military funding continue to flow from the U.S. to Israel.

The crime of extermination

According to the Media Office of the de facto authorities in Gaza, more than 500 bodies were found in mass graves located on hospital grounds, including at Shifa’ and Nasr hospitals. Satellite images from 23 April show at least two possible mass graves at Nasr Hospital. The de facto authorities in Gaza have said that several bodies were found undressed and handcuffed, indicating that the victims might have been executed. One witness involved in the exhumation of bodies near Nasr Hospital told the Commission that he had seen bodies with gunshot wounds in the head or neck. Israeli security forces have denied burying bodies in mass graves, although they acknowledged that soldiers searching for the bodies of hostages had exhumed some mass graves.

The commission concluded from its investigation that Israel has been guilty of the crime against humanity of extermination. Among its recommendations, it calls for U.N. member states, including the United States, to “cease aiding or assisting in the commission of violations; explore accountability measures against alleged perpetrators of international crimes, grave human rights violations and abuses in Israel and the Occupied Palestinian Territory.”

Crimes against humanity are, according to the NGO TRIAL International, those found on a list of specific crimes committed in the context of a large-scale attack on civilians. They are not quite the same as war crimes, since a “crime against humanity can also be committed in peacetime.” The most comprehensive and recent list of crimes against humanity is found in the 1988 Rome Statute of the International Criminal Court. Extermination is one of these crimes.

Just as a crime against humanity isn’t necessarily a war crime, extermination, Sidoti explained, is not the same thing as genocide. “Genocide does not need to involve a single killing. There are five acts that can constitute genocide, only one of which involves killing,” he said.

The genocide case against Israel, launched by South Africa on Dec. 29, 2023, and since joined by 10 other nations, including Ireland, Mexico and Türkiye, has not yet been decided by the International Court of Justice, which in January issued provisional orders. The ICJ considers the claims made by South Africa about possible rights violations constituting genocide to be plausible, and that the consequence of waiting for the ruling could be catastrophic.

By contrast, the commission’s October finding that Israel is committing the crime of extermination in Gaza relates to the commission of massacres, not to their purpose: “More significantly still, genocide must be these acts carried out with the purpose of destroying a protected group in whole or in part. Extermination does not involve that genocidal purpose. It is mass killing, but it need not be accompanied by a purpose to destroy the group in whole or in part,” Sidoti told Salon.

An aerial view shows the compound of Al-Shifa hospital in Gaza City on November 7, 2023, amid the ongoing battles between Israel and the Palestinian group Hamas. (BASHAR TALEB/AFP via Getty Images)There can be no question that mass killing has occurred repeatedly in Gaza in the last year, with over 93 massacres since March, according to Special Rapporteur Francesca Albanese’s report, which was released last month. The Flour Massacre. The Al-Aqsa Martyrs Massacre. The al-Tabin school-turned-shelter Massacre. The Nuseirat Market Massacre. The multiple massacres in Jabalia refugee camp and Beit Lahia neighborhood. The siege of Al-Shifa Hospital. The Al-Mawasi “safe zone” massacre. 

On Oct. 19, at least 73 people died as a result of Israeli strikes on Beit Lahia, a residential block made more crowded by displaced people ordered to evacuate Jabalia refugee camp and hospitals in the north. But the Israel Foreign Ministry posted in English on X: “Following an initial IDF examination, the numbers published by the Office of Hamas-run Government Information Office in Gaza — are exaggerated and do not align with the information held by the IDF, the precise munitions used, and the accuracy of the strike on a Hamas terror target.”

Indeed, the IDF is capable of extremely precise strikes. Back in 2012, the IDF Editorial Team described the Israeli Air Force’s ability to use so-called pinpoint targeting, “singling out terrorists and targeting them in a way which won’t endanger bystanders … IAF pilots can even single out one target from an entire residential complex.” They also noted the Air Force ability and willingness to abort an attack if it becomes clear that there are “civilians in the target zone.”

Unmanned aerial vehicles (UAVs) or drones are used extensively for risk-free surveillance, while armed UAVs or unmanned combat aerial vehicles (UCAVs), can shoot or snipe from above. Small drones, called quadcopters, may be used for surveillance or equipped to drop bombs. The buzzing sound of UAVs has been ubiquitous in Gaza since 2006, and drones are called zenana, an Arabic word referring to the sound using the slang term for a nagging wife.

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“It occurs to me that, for children born after 2005, they have no concept of a quiet sky,” Dorotea Gucciardo, who coordinates medical delegations to Gaza for Glia, an international NGO devoted to accessible healthcare, told Salon in a video interview. “They have no concept of a free sky, because everything in the sky is trying to kill them. It’s either trying to track them, to surveil them, to maim them, to target them, to kill them, whether it’s these quadcopters, whether it’s the drones, whether it’s the fighter jets.”

Breaking the Silence, an organization of Israeli veterans who oppose the occupation and testify to war crimes committed by the IDF, also addressed the question, writing on X about the killings of 120 people that resulted from the bombing of a hospital and a residential complex on the same weekend, which the IDF attempted to justify by citing its use of “precise munitions.”

“Unsurprisingly though, the dead don’t seem to care how ‘precise’ the weapons were,” the post reads. “And while the army may have considered them ‘acceptable collateral damage,’ basic moral norms say otherwise. Especially when the list of ‘acceptable’ targets includes humanitarian safe zones.”

“You can see we are burning and you stay quiet"

The period investigated by the U.N. commission ended in July. But the atrocities described in the report have not ceased: For example, the stun grenade dropped on a polio vaccination clinic during a humanitarian pause, wounding several children. The bombing of the third floor of a hospital that destroyed medical supplies brought in after days of negotiations just days before. The 13-year-old girl just out of surgery who was struck by shrapnel, causing a fresh and critical abdominal injury, during multiple strikes on a hospital while World Health Organization staff were present to carry out medical evacuations coordinated with Israeli forces. The doctor killed in an Israeli strike alongside her mother and her newborn twins, her husband finding their bodies at the morgue of her former workplace minutes after registering his babies’ birth. Patient wounds routinely crawling with maggots because health care facilities have no access to soap, gauze, disinfectant and running water. A hospital director calling daily on the international community to intervene to break the siege and bring surgeons and supplies to the nearly-ruined hospital where he is one of two remaining doctors amid a constant flood of suffering as Israel carries out forced displacement that may amount to ethnic cleansing of the north of Gaza.

By the beginning of last month, the World Health Organization reported 516 attacks on health care since the start of the war, an increase from the 498 attacks the commission reported between Oct. 7, 2023 and July 30, 2024.

The week before Salon spoke with Gucciardo in October, 19-year-old software engineering student Sha’ban Al-Dalou was burned alive as a result of a targeted Israeli strike that hit patient tents in the hospital courtyard of Al-Aqsa Martyrs Hospital, which, like the grounds of other major hospitals, has become an overflow site for patients and their families. As people around the world watched in video and photographs, Al-Dalou could be seen trying to move while engulfed in flames. A clearly visible IV ran from his arm. Al-Dalou’s mother was burned alive beside him while his father, Ahmad, managed to rescue two of his five children. As reported by The Times of Israel, the IDF said it had “struck terrorists operating from a command center inside the medical center’s compound and accused Hamas of hiding among civilians and using facilities such as hospitals for terror operations.”

Sha’ban’s brother, Mohammed, said in an interview with AJPlus, “I can't describe the feeling. I saw my brother burning in front of me. And my mother was burning. What more do you want to happen to stay quiet? You can see we are burning and you stay quiet.” 

Days afterwards, Al-Dalou’s youngest brother, 10-year-old Abdul Rahman, succumbed to his burns. Their cousin spent days calling out to the world on social media, begging for international intervention to secure the medical evacuation of Al-Dalou’s two sisters, whose condition has continued to deteriorate. There was no response. Farah died of her injuries around Oct. 20, leaving only 14-year-old Rahaf struggling to survive.

“It made a lot of people feel just totally helpless, like, what have we been doing? Why? Why can not even this galvanize change?” Gucciardo told Salon. “And then it made some of us feel more galvanized, like now is not the time to stop. Now is not the time to stop talking, to stop fighting, to stop demanding dignity for Palestinians in Gaza.”

International solidarity MIA

There has been a glaring disparity between medical associations’ eagerness to speak out about the Ukraine war and to advocate for protection of medical facilities and provision of humanitarian medical services, and the virtual silence regarding the complete destruction of the health care system in Gaza.

“The silence surrounding the targeted attacks on Gaza’s medical workers is a moral failure,” Dr. S. told Salon from the devastated north of Gaza, where all three remaining hospitals have been under Israeli siege and attack in recent weeks, with numerous medical staff detained in unknown locations. “This level of exhaustion and lack of support is unsustainable,” he said in late October. Nevertheless, this month S. decided to go back to help out at a different hospital but was displaced again on Nov. 7, his family’s fifth displacement in a month. He doesn’t know where they will end up.

It’s not just a question of statements calling for a ceasefire or for an end to U.S. funding for Israel’s war in Gaza, or expressing condemnation of attacks on health care facilities. No Palestinians, even if they can pay the exorbitant fees, are allowed to leave Gaza right now unless by medical evacuation. Since Israeli forces took control of the Rafah crossing between Gaza and Egypt in May, even those have become vanishingly rare. But while the desperate pleas of Sha’ban Al-Dalou’s cousin on social media have not been answered, medical evacuation remains possible — and it’s the host governments, or even host hospitals, that put the process in motion.

“The system inside Gaza is actually fairly efficient,” explained Dr. Amber Alayyan, an American pediatrician and the deputy cell manager for the Middle East Region at Doctors Without Borders. American hospitals can arrange and pay for the medical evacuation of sick or injured patients from Gaza.

It would “totally” be possible to bring “lots of injured people or sick people from Gaza,” Alayyan said. “It’s not that complicated. All there needs to be is the will, a real will. We’ve done this before,” she added, recalling examples of patients brought to the U.S. from various foreign countries for specialized treatment. “Each hospital can just say, ‘I have the space. I can take 10 kids, 15, 20, 30, 100 kids.’ Any hospital in the U.S., because it’s so privatized, could say, ‘We’re doing this, we’re going to make the space, and can get in touch with people from their local government or their state government, who can get in touch with people in the U.N.”

The hospitals, and those who help with advocacy and funding — whether that means individual health care staff, hospital directors, local health authorities, or the various national medical societies — would also be taking patients to a place of safety at a time when every person who remains in Gaza is at imminent risk of death.

As NPR reported in August, “an organization must have the surgery or treatment lined up along with transportation and funding,” and that’s the part any individual American hospital or medical organization could arrange. But the Israeli agency that coordinates government activity in occupied territories must also provide clearance for any person to leave Gaza, and often won’t do that until a host-country visa is in place. Approved evacuations have plummeted since May, from roughly 50 per day before Israel took over the Rafah Crossing, NPR’s Jane Arraf reported.

In July, the Palestinian Children’s Relief Fund, the largest NGO working on medical evacuations, reached an agreement with the WHO and the European Union’s Emergency Response Coordination Centre to bring children from Gaza to European hospitals for treatment, along with their accompanying immediate relatives. Early in November, the WHO announced that over 100 patients would be evacuated to the United Arab Emirates and Romania for treatment. The U.S. State Department has sometimes had success intervening with Israeli authorities to make evacuations happen.

“American medical associations are incredibly slow on moving forward,” Alayyan told Salon, and some “are not speaking out, for many reasons,” including the potential loss of donations. 

In 2023, the American Medical Association refused to debate a resolution calling for a ceasefire, while in June of this year dozens of health care professionals and students protested the AMA’s House of Delegates meeting in Chicago, where a compromise resolution calling generally for peace in Israel and Palestine ultimately won over resolutions that would have called explicitly for a ceasefire, condemned collective punishment tactics such as restricting access to food, water or health care, and opposed U.S. funding to entities that commit war crimes.

“I mean, the American Medical Association has a giant voice. The medical community in the U.S. has a huge voice,” Alayyan said. “It’s just striking how it’s become almost accepted by the international [community], or at least the West. No one’s really screaming and calling out [that] these are abject war crimes.”

A recent call to action by a loose international coalition of health care workers urged American health institutions like the U.S. Centers for Disease Control and Prevention, the National Institutes of Health, medical association presidents, hospital CEOs and other health care leaders to push elected officials for a ceasefire. It also asks health care institutions to support an arms embargo of Israel and divestment from companies implicated in violence.

But within the medical community in the U.S. there is little evidence so far of any move toward even a statement advocating against bombing hospitals.

Dr. Alice Rothchild is a retired OB-GYN and a member of Jewish Voice for Peace, a national, membership-based organization “working towards Palestinian freedom and Judaism beyond Zionism.” It’s the world’s largest organization of Jews who oppose Israeli policy in Palestine. JVP condemns Hamas’ war crimes, such as indiscriminate killing of civilians and taking of civilian hostages on Oct. 7 and beyond, and many of its members lost loved ones in the attack. As early as Oct. 11 the organization issued a call to prevent the imminent genocide of Palestinians in Gaza.

Rothchild notes that a bad faith conflation of antisemitism and anti-Zionism, or a reluctance to criticize actions of the State of Israel even when they violate international law, has led to a culture of silence and fear within the medical community.

In a video interview with Salon, Rothchild stated her views bluntly: “There is a genocide, there [are] now academic papers documenting the deliberate targeting of all health care institutions, health centers, health care workers” in Gaza. Gaza’s two schools of medicine, she added, have been bombed and its universities reduced to rubble. “Medical institutions [should] say this is egregious behavior, and we need to call it out. And we need to pressure Congress and Biden and anyone who has any power to stop this. The way to stop this is not to give Israel a free pass and not to send them billions and billions of dollars of weaponry that allow them to continue this genocide.”

“Medical professionals are allowed to criticize wars, anywhere else in the world, [to criticize] trauma anywhere else in the world,” she added. Yet the clear and obvious fact that war is a threat to public health remains a politically fraught position in relation to Gaza — even as time runs out for American doctors’ colleagues, and their patients, in the enclave.

“I was looking at the statistics the other day,” Alayyan said.“If 587 healthcare workers in Gaza have been killed, the equivalent in the U.S. is 92,000 people … So we hear these numbers, we go, that’s so small. Yeah, but the population is two million people. So if 92,000 healthcare workers in the States were killed, I feel like somebody would want to speak up. And it just seems shocking to me that doctors and health care workers in the States aren’t saying anything … There are many individuals who are speaking out, but the idea that these organizations that represent them aren’t is just disgusting.”