Six days after the Hamas-led massacre in southern Israel on Oct. 7, 2023, Israel ordered the evacuation of 22 hospitals in northern Gaza. In fact, 1.1 million people were ordered to evacuate the entire north of the enclave within 24 hours. But the evacuation of critically ill patients from nearly two dozen hospitals — a total of around 2,000 people, including newborn babies in incubators, patients on hemodialysis and life support — was not possible, certainly not quickly. The World Health Organization (WHO) condemned the order, calling it a “death sentence” for the sick and injured. Health care workers made the difficult choice to stay with their patients, even as their families were forcibly displaced to the south.

On October 17, 2023, there was a massive explosion in the parking area outside one of these hospitals — Al-Ahli Arab Hospital (also known as the Baptist Hospital, although it’s now run by the Anglican Diocese of Jerusalem). Having been displaced from their homes as Israel launched its offensive, thousands of residents were sheltering in and around the hospital, in addition to patients, families and staff.

According to the Gaza Ministry of Health, 471 people were killed directly in the explosion and many others wounded, some critically. Speaking as a representative of the ministry, Dr. Ashraf Al-Qadra condemned the incident as an expansion of Israeli attacks on Gaza to target the hospital system, though hospitals had already been hit by Israeli strikes. However, Israel denied responsibility. 

A month of analysis and debate followed, with governments including the United States; publications such as the Wall Street Journal and Agence France-Presse; and non-governmental organizations like Human Rights Watch launching their own investigations. “A year ago, after massive blast at #AlAhli Hospital, just questioning if Israeli forces might be responsible was to invite vilification. Today? So many hospitals, clinics, health professionals and patients have been targeted/killed in Gaza and Lebanon, it is impossible to keep track,” Alex Neve, international human rights lawyer and former Amnesty International Canada Secretary General, wrote last week during the sieges of the last three functioning hospitals in Gaza’s north. Yet the widely reported conclusion accepted by most media that fall was that misfired rockets set off by a Palestinian armed group were to blame. Israel didn’t do it. The world moved on.

That was many months ago, and many hospitals ago. Now, a report released this month by an independent commission of the United Nations describes Israel’s repeated and deliberate assault on health care infrastructure in Gaza. It specifically finds that:

Israel has implemented a concerted policy to destroy the health-care system of Gaza. Israeli security forces have deliberately killed, wounded, arrested, detained, mistreated and tortured medical personnel and targeted medical vehicles, constituting the war crimes of wilful killing and mistreatment and the crime against humanity of extermination.

The report will be presented to the U.N. General Assembly today. It’s more timely than ever. Just over a year after the Baptist Hospital explosion, multiple hospitals have come under direct attack by Israeli forces in recent weeks. Israeli forces withdrew on Monday from the last functioning hospital in north Gaza, Kamal Adwan Hospital, after days of direct strikes on the facility with shells and machine gun fire, hitting every hospital department and killing young patients after striking oxygen stations and the hospital generator.

Shortly after that, IDF soldiers stormed the hospital and arrested 44 male medical staff and some male patients. The hospital director's son was killed during the initial invasion of the facility two weeks before, when staff refused to leave their patients upon orders to evacuate. The director himself was arrested and later released.

The week before, the Indonesian hospital was similarly surrounded, shelled and directly attacked with artillery. Al-Awda, the third remaining hospital in this part of Gaza (there were previously 10), was also subject to strikes. Health care facilities in the center and south of Gaza continue to face similar attacks, which over the past year have involved strikes, sieges, forcible evacuations, and storming of hospitals across the Gaza Strip.

“I get updates from our teams or from people who are scouring the news just to figure out, ‘which hospital is on the list today?’” Dr. Amber Alayyan, an American pediatrician and the deputy cell manager for the Middle East Region at Doctors Without Borders, told Salon in a video call from Paris. She described a message from someone she works with: “it was like, all three of the hospitals in the north like ‘boom, boom, boom,’ one after another are under attack.”

It can no longer be denied, Alayyan said, that Israel is deliberately targeting hospitals, although Israeli authorities deny this. “Now it’s just sort of like … it’s just getting done, and it’s crazy to me that we’ve gotten so almost desensitized to it, or that no one’s really calling it out anymore,” she said.

Journalists in the north of Gaza reported last week that men detained both within hospitals and in the surrounding neighborhood were separated from women and made to march south. Drone footage from the weekend showed long lines of men and boys standing or walking in single file. As of this writing, their fate is unknown — however, by the following day the Israeli army itself released similar footage of the same scenes.

“It’s hard to describe, like a little part of my soul dies every time there’s a hospital that’s hit," Alayyan told Salon. “I cannot imagine this place, that is one of the safest places where you should be able to go, being a place that’s targeted.”

Alayyan said that despite repeated attacks targeting hospitals and hospital compounds, Palestinians in Gaza continue to flock to hospitals and the areas around them. Many thousands of people live in and around the grounds of the dwindling number of still-functioning hospitals across the territory, whether because they have family members who are patients or because they have themselves just been released from hospital and have nowhere else to go.

People inspect the damage caused by an artillery shell that hit the maternity hospital inside the Nasser Medical Complex, on December 17, 2023 in Khan Yunis, Gaza. (Ahmad Hasaballah/Getty Images)“In Gaza, I think people are sort of holding on for dear life to these hospitals,” Alayyan said, speculating that they persist in the idea that a hospital should be a safe place despite everything. “The people still go there, and the staff still rebuild them.”

The scale of the damage

Chris Sidoti is one of the three members of the COI, established by a resolution of the U.N.’s Human Rights Council in 2021 in response to “grave” concerns about human rights in the occupied territory. A lawyer, consultant and expert in human rights law, institutions and mechanisms, Sidoti previously served as a Member of the U.N. Independent International Fact Finding Mission on Myanmar.

“We do not find any fact without corroboration,” Sidoti told Salon, speaking from Australia in a video interview. “We interview victims and witnesses. We have done that both in person for medical evacuees from Gaza and members of their family who are accompanying them. We’ve been able to interview them in person, face-to-face. We also conduct interviews online, through telephone and internet, just like this, on Zoom.”

Sidoti confirmed that, based on the commission’s review of available evidence, the cause of that explosion in the courtyard of Al-Ahli Arab hospital almost exactly a year ago remains unclear. In other words, the commonly accepted conclusion that Hamas or other Palestinian forces were responsible cannot be taken as established fact — but neither can later analyses, also reviewed by the commission, such as this one concluding that only Israeli forces could be responsible.

The commission looked at events that took place from the Oct. 7 Hamas attack up to July 30, 2024, investigating allegations about the conduct of all parties involved. It finds that the state of Israel has repeatedly and deliberately targeted hospitals, carrying out 498 attacks on health facilities between Oct. 7 of 2023 and July 30 of this year. During that time, 500 medical personnel were killed, according to the Gaza health ministry.

A total of 747 people — patients, health care staff and families, including forcibly displaced people who took refuge in hospitals — were killed directly in those nearly 500 attacks on hospitals and clinics. According to the WHO, attacks analyzed between Oct. 7, 2023, and Feb. 12, 2024, involved military force (78% of all attacks), obstruction of access to health care facilities (35%) and militarized search and detention operations (9%.)

This is the third such investigation and report, and the second since Oct. 7, 2023. The commission’s mandate is to investigate and report annually to U.N. officials and the General Assembly on all alleged violations or abuses of international humanitarian and human rights law in the Occupied Territory, including East Jerusalem, and in Israel. A later resolution further requested the commission to “investigate all underlying root causes of recurrent tensions, instability and protraction of conflict, including systematic discrimination and repression based on national, ethnic, racial or religious identity.”

For its most recent report, the COI investigated the actions of both Israeli military forces and Palestinian armed groups, including Hamas, since the Oct. 7 attacks. Formal requests for information were made to the State of Israel, the State of Palestine, and Gaza’s Ministry of Health. As with previous reports, Israel did not respond.

---

Want more health and science stories in your inbox? Subscribe to Salon's weekly newsletter Lab Notes.

---

The Times of Israel reported in January that Israeli medical professionals were instructed by Israel’s Health Ministry not to cooperate with the U.N. commission, after it sent letters and emails to doctors and hospital staff who had treated Oct. 7 victims and returned hostages, as part of its investigation of international and gender-based crimes for a previous report, which was submitted to the Human Rights Council on June 12, and for the current one, which is being presented to the U.N. General Assembly this week.

The report is meant to summarize the commission’s investigation of “attacks carried out since 7 October 2023 on medical facilities and personnel, as well as the treatment of detainees in the custody of Israel and the treatment of hostages held by Palestinian armed groups.”

Salon contacted the Israel Defense Forces for comment and was referred to a response posted on X (formerly Twitter): “This report shamelessly portrays Israel’s operations in terror-infested health facilities in Gaza as a matter of policy against Gaza’s health system, while entirely dismissing overwhelming evidence that medical facilities in Gaza have been systematically used by Hamas and the Palestinian Islamic Jihad for terrorist activities.” 

Examining the evidence

Staff working on the report include a military expert, as well as experts on the use and admissibility of digital evidence. They use facial recognition and visual media authentication to determine the validity of the enormous volume of open source content that has been collected and preserved according to internationally-recognized standards.

“We’ve got an extraordinarily well-developed digital forensic capacity," Sidoti explained to Salon. “We’ve received and stored literally tens of thousands of items of digital evidence, which we do not accept without verification. We are able to access metadata. We can very easily dismiss some videos that … were taken in a different place at a different time. We’ve got the capacity to identify both geographical location and time.”

The report is not a legal proceeding, Sidoti explained, and commissioners did not seek to prove allegations “beyond reasonable doubt,” as in a court of law. Rather, their standard of proof was “reasonable grounds,” and where they couldn’t directly substantiate allegations themselves, they looked for reasonable grounds to believe they were true.  

“Our approach is total skepticism to anything we see on social media or any statement made by any authorities or by any allegations that are firsthand, until we investigate and corroborate,” Sidoti said. “And it’s only after investigation and corroboration that we make an assessment on whether there are reasonable grounds to come to a conclusion, and if there are, then we report on that.”

The commission’s findings will be used to inform the current case against Israel before the International Court of Justice for alleged acts of genocide in Gaza, as well as in future war crimes trials and other legal proceedings.

Conditions on the ground

Israeli security forces carried out air strikes against hospitals, causing considerable damage to buildings and surroundings, as well as multiple casualties; surrounded and besieged hospital premises; prevented the entry of goods and medical equipment and exit/entry of civilians; issued evacuation orders but prevented safe evacuations; and raided hospitals, arresting hospital staff and patients. Israeli security forces also obstructed access by humanitarian agencies.

In a text message interview conducted with Salon over several days over the past two weeks, Dr. S., a physician who worked at a hospital in north Gaza, described shortages of workers, food, medicine and equipment, and far too many patients. (Salon has agreed to protect this person’s identity.)

“We are also facing critical shortages of basic medical supplies such as gauze, iodine, alcohol swabs, and chlorhexidine for wound care. These essentials are crucial for preventing infection and promoting healing, but we are forced to ration what little we have,” Dr. S. said. At the start of the interview, he still worked, without pay, in the emergency department, but stopped after he and his family were displaced. 

“In our current situation, we are often faced with a critical need for stronger pain management options, especially when treating severe cases such as third-degree burns and traumatic amputations.” Dr. S. said, noting that medical staff lack proper antibiotics, which has contributed to the spread of antimicrobial resistance in Gaza and beyond, which can make some drugs fail to cure infections. “We are frequently resorting to broad-spectrum antibiotics like amoxicillin or ciprofloxacin, which are not suitable for all infections. This practice is contributing to increased bacterial resistance, a highly dangerous trend in a setting where infections are rampant and resources are already stretched thin.”

Dr. S. became trapped in Gaza by accident. He had returned from 10 years studying medicine abroad for a family visit only days before the Oct. 7 attacks — and then quickly lost 72 members of his extended family to Israeli air strikes. “It turned into a nightmare, I lost most of my family,” S. said. “They were simple, innocent people who just wanted a calm and loving life.”

S. watched as his former workplace was surrounded by Israeli forces, forcibly evacuated and shut down. Within a few days he heard that an emergency room doctor he worked with over many long nights had been shot by a drone inside Kamal Adwan hospital, and that the head of surgery at the Indonesian Hospital had been arrested at an Israeli checkpoint. “I hope I can make it through,” S. told Salon.

Well before October of 2023, many international medical volunteers have joined Palestinian doctors in trying to bolster the struggling health care system of Gaza.

Glia, an international NGO that began by creating low-cost medical devices and evolved to provide medical relief as part of its mission of “equal care for all,” is one of many organizations that contribute volunteer health care workers from the U.S., the U.K., and elsewhere. Its work is coordinated with the WHO, which itself coordinates with the U.N. and Israel.

“The Israelis are sending a very clear message that nowhere is safe,” Dorotea Gucciardo, who coordinates Glia’s medical missions to Gaza, told Salon days after strikes on the courtyard of Al-Aqsa Martyrs Hospital set fire to patients in tents. “They’ve made it very clear that hospitals, which are supposed to be protected areas, are not safe, and so by bombing them, they’re creating the conditions of making it impossible for people to live in safety and in dignity. And I think that ties directly to that U.N. report.”

Gucciardo notes that all of her local staff members have been displaced from their homes. “Every single one of them is affected — deeply, deeply affected by what’s happening,” she said. “One of my staff members very early in the war, the home next to hers was bombed, she had shrapnel all through her back. She’s had family members killed. She literally picked up the decapitated head of her uncle after his home was bombed.”

Another Glia staff member was at the market in Nuseirat refugee camp when drones began to shoot people on the ground, as part of an Israeli military operation that ultimately rescued four Israeli hostages, at the cost of at least 274 Palestinian lives.

“I have staff members who have watched their children die in front of them [after] their homes have fallen on them while they were sleeping because they were bombed,” Gucciardo went on. “Those are just the extreme stories. On a daily level, on a molecular level, they’re all struggling to find food, to find water, to find resources that will help their children feel safe.”

Before May 7, Glia was able to send seven to 10 international volunteers into Gaza every two weeks, bearing essential medical supplies, which cannot reach the territory by any other authorized means. Delegates have come from the U.S., Canada, the U.K., Ireland, Namibia and other countries. But on May 7, Israel took over the Rafah crossing previously controlled by Egypt, which for years has been the only exit point for Palestinians wishing to leave Gaza. Since the war began, Rafah has also become the only point of entry for medical delegations and humanitarian supplies. But since May 7, Glia has only been able to send about three delegates per month, and the amount of supplies they can bring in with them has been sharply reduced.

As of this October, Gucciardo said, Glia and six other aid organizations were banned entirely from sending medical delegations into Gaza.

“Each of these organizations has been operating in Gaza since at least January, providing medical personnel and supplies to assist various hospitals within the Gaza Strip. So it’s a real blow to upholding any kind of care for Palestinian patients,” Gucciardo added. 

The affected organizations hope that advocacy will result in regaining their delegation privileges. But time is not on anybody’s side. On Monday, Israel’s parliament passed a bill to ban the United Nations Relief and Works Agency for Palestine Refugees, or UNRWA, from operating in Gaza, which would reduce humanitarian aid even more drastically if it goes into effect.

Medicine under attack

The Commission investigated attacks on four hospitals in different areas of the Gaza Strip: the Nasr Medical Complex … and Shifa’, Awdah and Turkish-Palestinian Friendship … hospitals. Those include two major medical facilities and also hospitals that offer such specialized medical care as obstetrics, paediatrics and oncology. The Commission found that Israeli security forces attacked these facilities in a similar manner, suggesting the existence of operational plans and procedures for attacking health-care facilities.

“The Israelis talk about precise target bombing, but the extent of destruction of these hospitals indicate that in fact it was saturation, almost carpet bombing,” Sidoti told Salon. “The nature of the arguments that we used — the lack of proportionality relative to the alleged military use of the hospital. It all added up to an operation methodology that was common to them all and therefore can’t be considered to be coincidental.” 

In November of 2023, in response to an open letter (translated here) by close to a hundred Israeli doctors calling for the bombing of any and all Gaza hospitals, a group of doctors in Gaza responded, stating that doctors calling for the bombing of hospitals are “fully responsible for anything that might, God forbid, happen to the hospitals. Therefore, we demand and call on all of those that have to do with medicine and health — the World Health Organization and human rights organizations — to hold accountable those who are calling for destroying the hospitals and those inside them, destroying the hospitals and those working inside them and the wounded patients.”

According to the Ministry of Health in Gaza, 500 medical staff were killed between 7 October and 23 June. The Palestine Red Crescent Society reported that 19 of its staff or volunteers had been killed since 7 October, and that many others had been detained and attacked. Medical personnel stated that they believed they had been intentionally targeted.

In addition to targeted attacks on hospitals, clinics and ambulances, medical staff have been subject to mass arrests and detention along with patients. The COI notes that hundreds of medical personnel had been arrested and detained.

The COI’s findings are supported more recently by other organizations including Healthcare Workers Watch, which has documented the deaths or detentions of 105 senior physicians. In a report released this month, HWW describes systematic killing, detention and torture of health care workers including pharmacists, medical students, dentists and nurses, among others, and the killing of two of the last three pathologists in Gaza, as well as other specialists such as senior plastic surgeons.

In August, Human Rights Watch reported that doctors, nurses and paramedics released from Israeli detention described being personally subject to “humiliation, beatings, forced stress positions, prolonged cuffing and blindfolding, and denial of medical care. They also reported torture, including rape and sexual abuse by Israeli forces, denial of medical care, and poor detention conditions for the general detainee population.”

Detainees interviewed by HRW reported being pushed to confess to being part of Hamas with threats of indefinite detention, rape or the murder of their families in Gaza.

In recent weeks, numerous detentions of medical staff and patients, especially men, have been reported, with detainees allegedly taken to unknown locations. This has sometimes occurred after medical staff refused to follow orders to evacuate, leaving vulnerable patients or those unable to evacuate behind.

The COI writes in its report that “Israeli security forces have deliberately killed, wounded, arrested, detained, mistreated and tortured medical personnel” and notes that the use of sexual and gender-based violence has increased in intensity and prevalence along with the intensity of hostilities. They point to forced public stripping and nudity of men and boys, sexual humiliation of both genders, male detainees being subjected to attacks on their sexual and reproductive organs, and rape.

In February, U.N. experts condemned the use of sexual violence against women and girls in detention, and in August described substantiated reports by men and women of “detainees in cage-like enclosures, tied to beds blindfolded and in diapers, stripped naked, deprived of adequate healthcare, food, water and sleep, electrocutions including on their genitals, blackmail and cigarette burns. In addition, victims spoke of loud music played until their ears bled, attacks by dogs, waterboarding, suspension from ceilings and severe sexual and gender-based violence.” It is not known how many health care workers were among informants in these cases, but the HWW report documents first-hand accounts of similar methods of torture.

Israeli authorities have repeatedly alleged that hospitals are fronts for Hamas fighters and that health care workers may themselves be militants, including the claim, according to the U.N. report, that over 85% of major medical facilities in Gaza were used for terror operations by Hamas. The commission notes that Israel “did not provide evidence to substantiate that claim.” In Gaza, Hamas is the governing body, responsible for provision of social services and administration of public works. Hamas as a whole is identified as a terrorist organization by several countries, including the United States. The Gaza health ministry operates under the jurisdiction of Hamas, but not under its military wing.

An assault on the right to reproduce

The Commission finds that the deliberate destruction of sexual and reproductive health-care facilities constitutes reproductive violence and has had a particularly harmful effect on pregnant, post-partum and lactating women, who remain at high risk of injury and death. Targeting such infrastructure is a violation of women and girls’ reproductive rights and the rights to life, health, human dignity and non-discrimination. In addition, it has caused immediate physical and mental harm and suffering to women and girls and will have irreversible long-term effects on the mental health and the physical reproductive and fertility prospects of the Palestinian people as a group.

Gucciardo visited Gaza in March, bringing in diapers, sanitary supplies for women, other medical supplies and food when she crossed over from Egypt. Her staff had reported that a near-total lack of infant formula, with many new mothers so malnourished they could not produce breast milk, was resulting in babies starving to death. Gucciardo’s midwife staff helped women give birth in unsanitized rooms, due to lack of disinfectant.

“They didn’t even have basic supplies, like the scissors you would use to cut an umbilical cord. They were using a razor blade, you know?” Gucciardo said. “They would use a string from a face mask to tie off the umbilical cord.” 

Palestinian women and infants displaced from northern Gaza receive medical care at a clinic in Rafah, in the southern Gaza Strip, on February 29, 2024, amid ongoing battles between Israel and the Palestinian Hamas movement. (AFP via Getty Images)At Emirati Hospital in Rafah, the NICU director reported a spike in babies needing treatment — in part because the majority of Gaza’s population had been forcibly displaced into Rafah — but lacked sufficient resources to do so. Shortly before her arrival, he had three newborn infants who required ventilators, but only two devices.

“He had to make the decision which two babies to treat and which baby would die,” Gucciardo recalled. “He said that out of everything that he had seen up until that moment, all of the horrors that he had witnessed, that was the thing that made him cry the most, that killed him inside. And that has been repeated consistently. It’s not just in the NICU, but in every space, in every room in every hospital, these decisions about on who to use the resources that we have.”

Gucciardo later visited Nasser Hospital, the largest in the south of Gaza, with a local physician. Together they walked through the ruined building that remained after IDF troops pulled out on Feb. 22 following a month-long siege and forced evacuation. Gucciardo shared photos with Salon showing that every building in the complex was at least partly destroyed, with equipment smashed, wires cut, shelling pockmarks on walls or entire areas reduced to rubble, and graffiti scrawled on the walls still standing. At the time she visited, three mass graves had been discovered on hospital grounds.

“We went into the neonatal intensive care unit as well. Every single incubator was broken. Every single screen was smashed,” Gucciardo said.

Correspondence published in the Lancet this month details effects of the destruction of sexual and reproductive health infrastructure cited in the U.N. report, such as a surge in preventable deaths of mothers in childbirth and newborn babies, miscarriages, stillbirths and a massive increase in rates of premature labor.

“This reproductive violence,” the authors write, “is not just a consequence of the military assault — it is a deliberate outcome of policies that restrict access to health care.”

This explosive allegation of "reproductive violence" encompasses many things, such as the alleged targeting of maternity hospitals and fertility clinics and the alleged injuries inflicted on the genitals of male detainees. It also results from the drastic tightening since Oct. 7 of a blockade already in its second decade, restricting access to menstrual supplies, anesthetics, nutritious or adequate food, prenatal care, and sanitation, now including items as basic as soap.

“Without access to proper nutrition or health care, [women] are forced to carry pregnancies through conditions unfathomable to the human conscience,” the Lancet report states.

The evidence that Israel’s destruction of Gaza’s health care infrastructure is no accident is stark, and highly compelling to many outside observers. Will the commission report make a difference?

“That is a tragic question,” Sidoti told Salon. He sees no “realistic possibility” of a resolution that comes from any of the current leadership on any side. “This is the responsibility of states, and my expectation is that our reports will mainly have an impact at that level. It will affect the willingness or even the determination of other states to act to resolve this. It will also assist in international accountability, in having those that are responsible for the slaughter brought before international tribunals.”

That’s a process that’s already getting started. On Oct. 11, the Belgium-based Hind Rajab Foundation submitted the largest-ever complaint to the ICC, accusing 1,000 individually-named Israeli soldiers of participation in systemic attacks against civilians, constituting war crimes, crimes against humanity, and acts of genocide. The complaint is backed up by 8,000 pieces of evidence. 

The HRF has also started to file war crimes complaints against individual Israeli soldiers who are dual citizens. One soldier who is also an Ecuadorian citizen has been accused of war crimes relating to his participation in the assault on Al-Shifa hospital, and various complaints have been lodged against a Dutch-Israeli soldier accused of blockading access to food, water and medical supplies and directing attacks against medical personnel. In February, the Washington Post reported that there were 23,380 American citizens fighting with the IDF.

As Sidoti pointed out to Salon, and wrote in more detail elsewhere, the U.N. and member states bear responsibility for the current situation in Israel, the West Bank and Gaza, all of which was formerly the British Mandate Territory of Palestine. In 1947, the General Assembly decided via resolution 181(II) that this should be divided into “independent Arab and Jewish states.” The legitimacy of both states thus rests, in Sidoti’s view, on that resolution, which Israel’s rejection of Palestinian statehood violates.

“This dispute, unlike almost any other in the world, has been internationalized from the very beginning,” Sidoti said, “and there is therefore a continuing international responsibility for the resolution of the dispute.” But the parties involved, he added, “are not free to negotiate a resolution that would be contrary to international law.”

The real question, it would appear, isn’t whether Israel is targeting health care in Gaza. It’s why these extensive violations of international law have been allowed to continue, and why calls by health care workers for meaningful international support — including from American medical colleagues — are going unanswered after a year of suffering for Palestinians in Gaza.