The world has witnessed a near-unprecedented and ongoing humanitarian crisis in Gaza during the first 129 days of the Israel-Hamas war. Despite their critical role in saving lives, hospitals and other health care facilities—which are protected under international law—have not been spared the widespread destruction in the Palestinian territory, according to new research.
A study published Monday in the British Medical Journal Global Health from researchers at the Yale School of Public Health found that from October 7—the day Hamas launched an unexpected attack on Israel that left some 1,200 Israelis dead—to November 7, 2023, hospitals and health care facilities were damaged at the same rate as other buildings. The paper’s authors suggest that the Israel Defense Forces (IDF) did not take measures to ensure it did not strike these facilities, despite their protected status.
“This pattern of war, at least in this first month, looks like it was not really aligned with international humanitarian law,” says Danielle Poole, an associate research scientist at the Yale School of Public Health and lead author on the paper.
The United Nations Relief and Works Agency for Palestine Refugees in the Near East estimates that at the start of 2024, 85 percent of Gaza’s population, or some 1.9 million people, had been displaced by the conflict, and the Gaza Ministry of Health reports that at least 28,064 Palestinians were killed between October 7, 2023, and February 10, 2024. Human Rights Watch, a nonprofit watchdog organization, has characterized Israel’s attacks on health care facilities in Gaza as “apparently unlawful.”
Using high-resolution satellite imagery from the United Nations, data from the open source mapping platform OpenStreetMap, and known locations of medical facilities listed by the World Health Organization (WHO) and the United Nations Office for Coordination of Humanitarian Assistance, the researchers were able to identify damage to over 167,000 buildings during the first month of the conflict. Poole and her team found that 15,768 nonmedical structures and nine health care–related facilities suffered damage—about 9 percent in each case. The analysis also found that health care facilities were more likely than other buildings to have sustained severe damage or to have been destroyed completely.
“Already in this first month, their health system was severely compromised due to the conflict,” says Poole. As the researchers note in their report, the attacks on medical facilities “will undoubtedly have long-term effects on the health system through the severely decreased ability to provide necessary medical care to the population.”
Researchers ranked the damage done to buildings in four ascending categories: “possible damage,” “moderate damage,” “severe damage,” and “destroyed.” Poole says the numbers noted in her team’s report are conservative because they don’t count smaller medical facilities, like pharmacies or small clinics. “You wouldn't expect an artillery officer to know about the little pharmacy in the strip mall, even though those things are still protected” under international humanitarian law, she says.
International humanitarian law prohibits attacks on hospitals and health care facilities, or against patients, doctors, and their means of transport, during a conflict. A health care facility can lose its protected status if it is used to “commit acts that are harmful to the enemy,” according to the International Committee of the Red Cross (ICRC).
“Hospitals have special protection status underneath the Geneva Conventions and the Law of Armed Conflict,” says Nathaniel Raymond, a human rights investigator and a coauthor of the study. “To intentionally strike a hospital, the protocol required is the most restrictive for any type of civilian infrastructure. An armed party to a conflict must ensure that the hospital is notified that it has lost protected status, and efforts are made to ensure the evacuation of those facilities prior to any kinetic strike. That is what the law requires.”
In a lengthy response to WIRED’s questions about what measures it has taken to prevent damage to health care facilities, the IDF defended its military operations. “A central feature of Hamas’ strategy is the exploitation of civilian structures for terror purposes,” says an IDF spokesperson. “It is against this context of widespread exploitation of medical facilities and intelligence indicating their knowledge and even participation in terror activities that Israel has apprehended and questioned individuals in Gaza, including medical staff. We reiterate that individuals found not to have been involved in terrorist activity are released after questioning.”
The IDF has alleged that Hamas was operating out of tunnels underneath Al-Shifa, the largest hospital in Gaza, thereby making it a legitimate target. IDF forces raided the hospital on November 15. The tunnels have not been proven to have had a military function, and the legality of that IDF military operation remains in dispute.
Even in cases where the military has leveraged civilian structures, combatants are expected to exercise what IHL dubs “proportionality” and “precaution,” meaning that any attack should be done such that civilian harms do not outweigh the military benefit. “This does not mean there’s free license to attack,” ICRC chief legal officer Cordula Droege said in an ICRC video posted November 2 on X. “The party to the conflict has to do everything feasible in order to avoid or at least minimize harm to patients and medical staff.”
Although the destruction of health care facilities in Gaza is far more extensive, the WHO also recorded “33 attacks on health care in Israel during the violent events of October 7.” The WHO cautioned Hamas and Israel to remember “their obligation under international humanitarian law to respect the sanctity of, and actively protect, health facilities.” An independent UN Human Rights Council commission also says it is “collecting and preserving evidence of war crimes committed by all sides since 7 October 2023.”
The implications for Gaza’s health system have been disastrous. Even in the earliest weeks of the conflict, doctors warned that hospitals were running out of space to treat the wounded and were operating without access to anesthetics or even clean water. Hospitals and the health care system have also seen continued destruction. On January 3, the WHO estimated that only 13 of the 36 hospitals in Gaza remained operational. The WHO also says that instances of disease in Gaza have skyrocketed as access to health care, food, and clean water has plummeted.
Poole says she hopes the research leads to further investigations to “ascertain whether or not the medical complexes were getting distinction, proportionality, and precaution principles that protects them through IHL” throughout the course of the conflict.
“If the principle of distinction was being respected in this conflict, there would be a stark difference in our findings between special protected infrastructure—in this case, health facilities—and non-health facility infrastructure,” Raymond says. “What we find instead is that there is no difference.”
Update: 2/12/2024, 8:40 am ET to clarify the description of the satellite material on which the researchers based their analysis.
Update: 2/21/2024, 10:35 am ET: Following the publication of this piece, the British Medical Journal removed the study from its website, citing a “production error” that caused it to be published early, according to BMJ spokesperson Emma Dickinson. In a statement to WIRED, head researcher Danielle Poole says, “The article was accepted December 28, 2023, following peer review. We received an electronic notification that it was published with a public link on February 12, 2024. Subsequently, we were informed by the journal that it was prematurely published and that they had not completed their process.” Dickinson did not respond to WIRED's specific questions about BMJ's decision to remove the paper.
Update: 4/5/2024, 9:45 am ET: The British Medical Journal has republished the research paper.
