The Systematic Destruction of Healthcare in Gaza

[Anna-Christina Schmidl is a legal advisor with the International Humanitarian Law Centre. Eitan Diamond is a manager and senior legal expert at the International Humanitarian Law Centre.]

Introduction

The smashed city stretched to the frozen river. International law prohibited the targeting of medical facilities, which explained why, in a city where eighty percent of freestanding structures had been flattened, the hospital still stood.

This is an excerpt from A Constellation of Vital Phenomena, Anthony Marra’s masterful novel about war-torn Chechnya; some 20 years ago, after a devastating siege by Russian forces, the United Nations described its capital Grozny as “the most destroyed city on Earth.” 

Reading this passage today inevitably brings to mind images of Gaza, which has become a “moonscape” devastated by 20 months of hostilities. 

According to the Ministry of Health in Gaza, as of 25 June 2025, more than 56,000 Palestinians have been killed, and over 132,000 others have been injured; the vast majority of Gaza’s population has been displaced, often many times over. A complete Israeli blockade on the entry of humanitarian aid and commercial supplies into Gaza, only nominally lifted at the end of May and partially replaced by an unlawful Israeli-imposed delivery scheme which has led to mass killings by the Israeli military, has imposed conditions of starvation. Most homes and civilian infrastructure have been destroyed or damaged. 

And in Gaza, unlike in Marra’s fictional rendering of a Chechnyan city, hospitals too have been flattened. Those that are still standing have sustained serious damage notwithstanding their special protection under international law.  

The Health Cluster for the occupied Palestinian territory (oPt) led by the World Health Organization (WHO) estimates that despite a sharp increase in medical needs, as of 11 June, only 17 out of 36 hospitals in Gaza are still partially functional (and “none in Rafah and North Gaza”). According to the Gaza Health Ministry, as of 25 May, more than 1,500 health workers have been killed. 

Already at the end of April, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) in the oPt reiterated its warning that “Gaza’s health-care system is on the brink of collapse, overwhelmed by mass casualties and critically hindered by the full blockade that has cut off essential medicines, vaccines, and medical equipment, severely impeding lifesaving services.”

Building upon a recent publication by the IHL Centre, this post examines the systematic destruction of Gaza’s healthcare system throughout the hostilities, which stands to erode the protective framework for medical personnel, medical units, and medical transports set out in international law and imposes conditions of life that seem calculated to bring about the physical destruction of Palestinians in Gaza.  

Erosion of Protections 

At a fundamental level, international humanitarian law (IHL) seeks to protect the wounded and sick in both international and non-international armed conflicts since they do not take part in hostilities (Art. 8(a) AP I). As a corollary, it also offers protection to those entrusted with their care – medical personnel (Art. 8(c) AP I), medical units (Art. 8(e) AP I), and medical transports (Art. 8(f) AP I). Medical personnel, units, and transports exclusively assigned to medical purposes by a party to an armed conflict must be respected and protected in all circumstances (CIHL Rules 25, 28, and 29). They may not be intentionally targeted in the conduct of hostilities, nor may their duties or functioning be interfered with in the course of military operations; positive steps should be taken to facilitate their work (Commentary to CIHL Rules 25, 28, and 29). 

This special protection may be lost temporarily only if they commit, or are used to commit, outside of their humanitarian function, acts hostile to the enemy, and if a warning has been given – where appropriate, accompanied by a reasonable time limit – that has remained unheeded (Art. 13(1) AP I; Commentary to CIHL Rules 28 and 29; Sassòli, para. 8.021). In case of doubt, the presumption must be that they are not committing, or are not being used to commit, outside of their humanitarian function, acts hostile to the enemy. 

In the conduct of military operations, if special protection has been lost, the work of medical units, medical transports, and medical personnel may be interfered with, provided that the party carrying out the operation complies with its obligation to take constant care to spare the civilian population (CIHL Rule 15), and arguably also the general principle of proportionality in IHL. 

In the conduct of hostilities, loss of special protection in and of itself does not mean that the medical personnel, unit, or transport may be lawfully targeted. If their special protection is lost, they are still protected from attack as civilians and civilian objects. Thus, medical personnel may be intentionally targeted only if and for such time as they directly participate in hostilities, and medical units and transports may be intentionally targeted only if they meet the definition of a military objective (CIHL Rule 8). Furthermore, the attacking party must at all times comply with the principles of distinction, proportionality (including reverberating effects), and precautions (CIHL Rules 1, 14, and 15) in all attacks that may affect medical personnel, medical units, or transports. 

Grave concerns have been raised that Israel has been systematically disregarding these rules in Gaza – with devastating results. By way of example, the IHL Centre found apparent violations in the context of attacks and military operations on and around the premises of the Indonesian Hospital, Kamal Adwan Hospital, and Al-Awda Hospital in North Gaza while the governorate was placed under siege by Israeli forces from October 2024 until the ceasefire in January 2025.

Related concerns have been raised by other actors, such as the Office of the United Nations High Commissioner for Human Rights (OHCHR), Al Haq, and Human Rights Watch. 

Similar conduct appears to have been ongoing since Israel’s resumption of hostilities in March amidst attacks on Nasser Hospital, Al-Ahli Hospital, Al-Durrah Pediatric Hospital, and the European Hospital, for example. In another incident in March that drew international outrage, Israeli forces shot 15 clearly identifiable paramedics and rescue workers at close range and buried them in a mass grave alongside their vehicles. 

In addition, at the end of May, the Indonesian Hospital and Al-Awda Hospital – which had been attacked and the former raided during Israel’s siege of North Gaza at the end of 2024 – were once again surrounded by Israeli troops; the remaining patients at Al-Awda Hospital were subsequently forced to evacuate, and the facility stopped operating, reportedly leaving no functional hospitals in the governorate. 

Furthermore, in early June, it was reported that Israeli military operations in the proximity of Nasser Hospital in Khan Younis were posing a threat to patients, staff, and its continued functioning. The facility plays an essential role in the delivery of medical services in the south of the Strip, where around one million persons are believed to be sheltering in a catastrophic environment; the WHO called Nasser Hospital “the most important referral hospital left in Gaza” and warned of dire consequences should it cease operations. 

Even if one were to accept the basic premise of Israel’s claims that Hamas is unlawfully using civilian infrastructure, including hospitals and ambulances, for military purposes – and there are indeed indications that this may be the case, though the full extent of Israel’s allegations cannot be independently verified – this would not justify Israel’s conduct. 

The legal framework on the special protection for medical personnel, units, and transports (as well as their loss of protection) was designed precisely to address such challenges. When encountering these challenges, the protections set in the law must therefore be presumed to be applicable – barring sufficient evidence to the contrary – and must be respected. Israel’s documented patterns of conduct in Gaza raise grave concern that it is adopting the reverse presumptions and simply disregarding protections. In this regard, it is important to note that violations of IHL by one party to an armed conflict do not entitle the other party to disregard its own obligations. 

Failure to push back against Israel’s conduct in Gaza – which appears to have turned hospitals into “battlegrounds” and “‘scrubs and white coats’” into “‘target[s] on [the] backs’” of health workers – stands to erode the protections for the wounded and sick as well as medical personnel, medical units, and medical transports in other armed conflicts. There have been concerning developments in this regard also in Sudan, Ethiopia, and Ukraine, for example, as well as in the context of the hostilities between Israel and Iran; on 19 June, an Iranian missile reportedly struck the Soroka Hospital in southern Israel, causing significant damage to the facility.

Deprivation of Life-Sustaining Resources

Israel also has obligations pursuant to the law of occupation in Gaza that are “commensurate with the degree of its effective control” (Advisory Opinion of 19 July 2024, para. 94). 

Accordingly, it must maintain or restore, as far as possible, public order and civil life in the Strip (Art. 43 Hague Regulations) and refrain from destroying property in the occupied territory except where absolutely necessary for military operations (Art. 53 GC IV). Israel must also ensure, to the fullest extent of the means available to it, the food and medical supplies of the population as well as ensure and maintain, as far as possible and in cooperation with the national and local authorities, the medical and hospital establishments and services as well as public health and hygiene (Arts. 55 and 56 GC IV). In case the population in the occupied territory is inadequately supplied, it must agree to the provision of relief schemes and facilitate them by all means at its disposal (Art. 59 GC IV). 

Israel also has obligations under international human rights law in the oPt (Advisory Opinion of 19 July 2024, paras. 97-101) – for example, ensuring the right of Gaza’s population to the highest attainable standard of health (Art. 12(1) ICESCR). 

Even accounting for conditions of hostilities, which may impact the scope of what is feasible for an occupying power when discharging its obligations, Israel appears to have been systematically disregarding its duties. 

It has failed to cooperate sufficiently with the local health authorities – or, in the alternative, with the World Health Organization or similar relief organizations – for purposes of ensuring the medical care of the population. As documented here, for example, Israeli forces have detained medical professionals and subjected them to systematic torture and ill-treatment. Not only is this absolutely prohibited conduct (CIHL Rule 90), it also prevents them from providing medical services to patients in need. Hospitals and health facilities have long been operating amidst a severe shortage of supplies, leaving patients to scream in agony while undergoing surgery without anaesthetics and condemning those with chronic illnesses to their fate; the complete blockade imposed since 2 March and only nominally lifted at the end of May has gravely exacerbated situation. Finally, there have been instances in which Israeli forces appear to have destroyed medical equipment in hospitals that had come under their control, and the Turkish-Palestinian Friendship Hospital – the only specialized facility for cancer treatment in Gaza – was blown up in a controlled demolition at the end of March. 

Cumulative Effect 

Taken together, the destruction of the healthcare system due to a lack of supplies, the detention, killing, and injuring of medical personnel and patients as well as repeated attacks and raids on and around hospital premises in contravention of the applicable legal framework have resulted in a catastrophic situation for the civilian population in Gaza. 

This does not only entail individual IHL violations that may constitute war crimes; the cumulative scope and effect, as it were, is greater than the sum of their parts. 

For one, the destruction of Gaza’s healthcare system may entail the commission of crimes against humanity – defined as a number of inhumane acts “committed as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack” (Art. 2(1) Draft Articles on Prevention and Punishment of Crimes Against Humanity). The arrest warrants issued by the ICC for Israeli Prime Minister Benjamin Netanyahu and former Israeli Defence Minister Yoav Gallant – which concern individual criminal responsibility – included the crime against humanity of other inhumane acts for restricting the entry of medicine and medical supplies into Gaza.  

The destruction of the medical system in Gaza may also entail the commission of one or more of the constitutive acts of genocide, such as deliberately inflicting on a protected national, ethnic, racial, or religious group conditions of life calculated to bring about its physical destruction in whole or in part (Art. II(c) Genocide Convention). The ICTY has held that this covers, for example, “subjecting the group to a subsistence diet; failing to provide adequate medical care… and generally creating circumstances that would lead to a slow death such as the lack of proper food, water, shelter, clothing, [and] sanitation” (Prosecutor v. Tolimir, Appeals Judgment, para. 225, and the references cited therein). The Elements of Crimes of the ICC similarly provide that creating such “conditions of life” may encompass the “deliberate deprivation of resources indispensable for survival, such as food or medical services” (Art. 6(c), fn. 4). 

The International Court of Justice repeatedly found in its orders on provisional measures in the South Africa v. Israel case that the rights invoked by South Africa – that Palestinians in Gaza constitute part of a protected group and may not be subjected to acts prohibited under the Genocide Convention, and that South Africa has an erga omnes partes entitlement to invoke Israel’s responsibility for alleged breaches of the Convention – are plausible. 

Final Thoughts 

Many of Gaza’s hospitals no longer stand; the medical system has been decimated, and lifesaving aid is being denied. For the wounded and sick, the lack of treatment may lead to lifelong illness or amount to a death sentence. For the entire people of the besieged and bombarded enclave, the destruction of healthcare aggravates conditions of dire deprivation, threatening their very survival. 

Especially in a situation where the primary duty bearer – Israel – systematically disregards its obligations under international law, the role of third States is crucial. They have robust obligations to prevent violations of IHL, to bring ongoing violations to an end, and to prevent genocide and crimes against humanity. They must also ensure that individual perpetrators suspected of having committed serious international crimes are held accountable. 

Whether third States will actually muster the political will to take action after 20 months of hostilities remains to be seen – what is clear is that their (continued) failure to do so only stands to further erode the crumbling foundations of the rules-based international order.