UN OCHA reported that since 7 October, nearly two-thirds (46 of 72) of primary health care clinics in Gaza have shut down due to damage or lack of fuel, increasing the pressure on the remaining health facilities that are still operational. As we write, according to the Palestinian Ministry of Health, almost half of the hospitals in Gaza (16 of 35) are no longer operating.
The World Health Organization (WHO) indicated that all drugs and medical supplies in Gaza are depleting, including those needed for acute and emergency care (including anaesthesia), for treatment of chronic conditions such as insulin, and lifesaving drugs for newborns, cancer patients, and those requiring intensive care. Prior to 7 October, an average of 100 patients per day were able to cross the Erez crossing, pending the issuance of an Israeli-exit permit, to access medical treatment in hospitals in the West Bank, including East Jerusalem, and Israel. On 1 November, 81 wounded Palestinians were reportedly allowed to cross Rafah and reach an Egyptian field hospital—a disturbing figure, considering that the number of wounded in Gaza has exceeded 22,000.
All hospitals in northern Gaza have received evacuation orders from the Israeli military, which are impossible to execute. Thousands of patients and medical staff, as well as about 117,000 internally displaced persons (IDPs), are staying in these facilities. The WHO strongly condemned Israel's repeated evacuation orders, and referred to them as “a death sentence for the sick and injured”. UN OCHA reported that over the past days, the vicinity of Al-Shifa and Al-Quds hospitals in Gaza City and the Indonesian Hospital in Beit Lahiya have been bombed by Israeli forces, causing damage. This followed renewed orders from the Israeli military to immediately evacuate all ten hospitals still operating in Gaza City and northern Gaza.
According to the Palestinian Health Ministry, since the beginning of its retaliatory aggression on Gaza, and as of 31 October, the Israeli military has killed 124 medical personnel and attacked and destroyed 25 ambulances.
Al-Quds Hospital
At around 9:30 a.m. on 29 October, the Israeli army ordered the Palestinian Red Crescent Society (PRCS) to immediately evacuate Al-Quds Hospital, in Tal al-Hawa, south of Gaza City, pending an imminent attack. The PRSC—an independent humanitarian organization that is part of the International Red Cross and Red Crescent Movement—reported that since the morning, there have been repeated Israeli attacks in Tal al-Hawa and the vicinities of the hospital. The PRSC already announced that they have no means to evacuate: the hospital is currently treating hundreds of patients, including nine connected to breathing machines in the intensive care unit (ICU). Al-Quds hospital is also sheltering 14,000 civilians—mostly children and women—who have nowhere else to go. Among them, are 400 patients with chronic diseases and disabilities currently being treated at the hospital.
Due to Israel's total siege and the lack of humanitarian aid—so far largely inadequate in quantity and only distributed in southern Gaza—hospital staff, patients and civilians sheltering within the hospital premises have severe difficulty accessing food and water. Three ambulances have stopped working because of the lack of gasoline. The PRSC also reported that Israeli airstrikes are hitting and destroying buildings up to 50 meters away from the hospital, getting closer by the day. Nonstop airstrikes in recent days have caused damage to the hospital, including broken window panes and part of the ceiling collapsing. Strong tremors have also been reported in the facility due to the proximity of the bombing.
This is not the first time the Israeli military has threatened to target Al-Quds Hospital. On 20 October, the PRSC already warned that they were facing an “imminent threat” of being targeted by Israeli attacks as the Israeli army demanded the evacuation of hundreds of patients, medical and humanitarian personnel, and thousands of civilians who were already sheltering within the hospital premises.
Indonesian Hospital
On 30 October, Israel attacked the immediate surroundings of the Indonesian Hospital in Beit Lahiya, northern Gaza. The Indonesian Hospital, along with Al-Shifa Hospital, is one of the largest healthcare facilities in the entire Gaza Strip.
Repeated shelling around the hospital had already destroyed parts of the roof. The spokesperson of the Palestinian Health Ministry in Gaza, Ashraf Al-Qudra, stated that the attack “greatly damaged the hospital and endangered the life of hundreds of injured, patients, medical staff, journalists, as well as thousands of displaced persons taking shelter therein”. The Indonesia Hospital is currently sheltering 1,500 Palestinians who fled their homes seeking a safe place from Israel’s heavy bombardments, while some 164 patients are still hospitalized. The hospital has been working beyond its capacity and struggling with medicine and fuel shortages. As of today, 2 November, the Indonesian Hospital has run out of fuel and shut down its main generator. It is left with small power generators to keep the ventilation system and ICU units running.
The Palestinian Health Ministry in Gaza had already warned about this happening. The Indonesian Hospital and Al-Shifa Hospital together have 42 newborn babies on life support systems in incubators, 62 patients and persons injured on ventilation systems in ICU, and 650 kidney dialysis patients.
Turkish-Palestinian Friendship Hospital
The Turkish-Palestinian Friendship Hospital is the only medical facility in all of the Gaza Strip offering treatment to oncology patients. The Israeli military has targeted the hospital and its vicinity several times since 7 October, damaging the building and electromechanical systems, and leaving cancer patients in a state of panic. On Wednesday, 1 November, Dr. Subhi Skaik, the hospital’s director, announced that the facility was no longer functioning because of a lack of fuel and damage due to Israeli airstrikes in its vicinity over the past days. Tedros Adhanom Ghebreyesus, the Director-General of the WHO, commented that “[n]o words can describe our concern for the patients who have just lost the only possibility to receive lifesaving cancer treatment or palliative care. I urge and I plead - for full medical and fuel aid access NOW! The more we wait, the more we put these fragile lives at risk.” The Palestinian Health Minister Mai al-Kaila said on Wednesday that “[t]he lives of 70 cancer patients inside the hospital are seriously threatened.”
Al-Shifa Hospital
Our organizations are equally concerned about threats of a possible Israeli attack targeting Al Shifa Hospital, Gaza’s largest medical complex. Al Shifa Hospital, located in Gaza City, and known to be the Strip’s central and largest medical complex, is currently treating thousands of injured patients and sheltering more than 50,000 civilians with nowhere else to go.
On 27 October 2023, the spokesperson for the Israeli army incited for the targeting of the Al-Shifa Hospital. The pretext for this claim is the alleged presence of tunnels beneath it, a claim repeatedly made by Israel that has not been substantiated with any reliable evidence. Al Mezan, Al-Haq, and PCHR express concerns that this could be a prelude to justify the potential targeting of the hospital, as seen in previous incidents, potentially leading to thousands of civilian casualties.
While facing threats of being targeted, on 31 October, the Palestinian Health Ministry issued a last warning before the shutdown of the main electrical generator in the Al-Shifa Medical Complex, stating that there are only a few hours left before going out of service. Moreover, while Al-Shifa Hospital is working at full capacity, some patients from the hospital’s maternity ward were transferred to Al-Hilo Hospital, in the centre of Gaza City, which was also struck by shelling on 1 November. It is reported that there are around 50,000 pregnant women in the Strip, and around 160 babies are born per day.
Respecting and Protecting Health Care in Armed Conflicts
Under international humanitarian law (IHL), medical units must be respected and protected at all times and must not be the object of attack. Parties to the conflict also cannot prevent hospitals or medical units from performing their life-saving functions for the wounded and sick.
Given their life-saving functions, hospitals enjoy special protection from direct attack, which is lost only if they are used to commit acts harmful to the enemy. Harmful acts may include, for example, “the use of a hospital as a shelter for able-bodied combatants or fugitives, as an arms or ammunition store, as a military observation post, or as a centre for liaison with fighting troops”. That being said, “[t]he fact that sick or wounded members of the armed forces are nursed in these hospitals, or the presence of small arms and ammunition taken from such combatants and not yet handed to the proper service, shall not be considered to be acts harmful to the enemy”.
By virtue of their special protection, the attacking party must do everything feasible to ascertain that hospitals have lost their protected status. This assessment must be based on facts and not on assumptions, false information or propaganda. When hospitals lose their protective status, they must be given a reasonable and feasible warning before being attacked. Special protection only ceases after such warning has remained unheeded. Nevertheless, this does not mean that there is a free license to attack: the principles of distinction and proportionality still apply to the attacking party. Intentionally directing attacks against hospitals absent legitimate military considerations of harmful acts, constitutes a war crime under the Rome Statute of the International Criminal Court.
In addition to prohibiting attacks on medical units, IHL prohibits the attacking of persons hors de combat including those who are “defenseless because of unconsciousness, shipwreck, wounds or sickness”. IHL also confers upon the parties to the armed conflict the duty to protect and care for the wounded, sick. Attacking hospitals treating the wounded and sick violates these provisions.
Conclusion
With each passing hour, Gaza’s healthcare system is nearing complete collapse. Almost half of the hospitals in Gaza are no longer operating or are about to exhaust their fuel reservoirs and medical supplies. All hospitals in northern Gaza, currently sheltering thousands of civilians, have been ordered to evacuate. In light of this, and as Israel continues to make medical personnel and medical units the object of the attack, our organizations conclude that Israel has demonstrated a systematic pattern of attacking Gaza’s healthcare system.
We reiterate the special protection afforded to civilian hospitals when used for humanitarian duties. The protection enjoyed by Palestinian civilians in northern Gaza, regardless of whether they are willing or able to follow Israel’s evacuation orders, remains untouched. Israel must continue to apply the principles of distinction, proportionality and precautions in each and every single attack.
Under IHL, it is prohibited to “attack, destroy, remove or render useless objects indispensable to the survival of the civilian population”, including the provision of supplies, “whether in order to starve out civilians, to cause them to move away, or for any other motive”. The denial of medical aid and fuel into the Gaza Strip, necessary for the survival of the civilian population, clearly contravenes international humanitarian and human rights law, in particular the right to life and the right to health. It is not not only an illegal collective punishment, but it also amounts to the crime against humanity of persecution and possibly to the crime against humanity of extermination.
Given the gravity and scale of the crimes we are witnessing in Gaza, the international community must urgently intervene to bring this military offensive to an immediate end. Full, sufficient, and unconditioned humanitarian aid must be immediately facilitated to enter and distributed throughout the Gaza Strip and medical patients in critical conditions should be allowed to access medical care outside of Gaza, including through Erez and Kerem Shalom crossings.
We once again call on the Member States of the UN Security Council to call an emergency session, appeal to the United States and the United Kingdom to refrain from exercising veto powers, and call for an immediate ceasefire.