Gazan Healthcare: Humans Are Not Collateral

Introduction

The failure of humanitarian law in wartime: 34,000 and rising deaths in the Israel-Hamas conflict. Where is the protection of international law when we need it? Why are medical facilities continuously under attack?

The increasing death toll demands urgent attention to the growing healthcare crisis in Gaza specifically. This article dives into the worsening problem of food insecurity and disease among war civilians, access to humanitarian aid, and global policies designed to protect humans during conflict. Healthcare is a human right, especially in a time of war. Unfortunately, history reveals a common story of attacks on medical facilities in conflicts dating back to the 19th century. Only more recently have these attacks been reported enough for people to start caring on a global scale. In consequence, research studies on violence against healthcare have amounted to almost 1,5000 articles and literature reviews.^[1]

Conflict in a Snapshot

Before discussing the collapse of Gaza’s healthcare system, here is a brief snapshot of the Israel-Hamas conflict explained to understand why a humanitarian crisis is occurring in the first place. Since the early 1900s, strong ethnic nationalism has divided Jews and Palestinians. In 1920, a British mandate was imposed upon Palestine after World War I. Post World War II, the mandate was lifted and the UN approved Israel and Palestine as separate nation-states. Yet, with growing tension about defining boundaries, conflict between Jews and Palestinains has ultimately led to Jewish sovereignty and occupation in Palestinian territories like Gaza and the West Bank. Displacement and discrimination of Palestinians over half a century birthed the terrorist organization Hamas. In 2005, Hamas wrested control of Gaza from Israel, bringing us to the current war between Israel and Hamas.

Disease

The exacerbation of conflict is actively destroying the healthcare system in Gaza through displacement and air bombings. Under the war violence of Israel and Hamas forces, “75% of Gaza’s 2.7 million residents” to be displaced.^[1] Hospitals that were temporarily housing displaced Palestinains– a ‘safe space’ for civilians– are now overcrowded. With the increasing number of people seeking shelter and the urgent attention needed towards wartime patients, medical facilities are becoming increasingly unsanitary. With a horrifying depletion of medical supplies, the absence of culture bacteria and hygiene supplies exacerbates infection outbreak. A growing lack of fuel also impedes water desalination and electricity to run the hospitals. Electricity is incredibly invaluable to operate testing facilities, and the absence of it has “left infections undiagnosed, allowing pathogens to spread more easily.”^[2] Prominent diseases are cholera, diarrhea, and malnutrition. This is especially true among children who are the most susceptible group. Health experts are concerned with the life-long health problems guaranteed after war conflict.

Food Insecurity

Sky-rocketing cases of malnutrition among displaced civilians also highlights the worsening food insecurity in Gaza. War bombings are destroying farmland for agricultural production and local food manufacturers have become disoperational. As a result, the risk of a catastrophic famine begins to grow as civilians in the Gaza Strip now almost completely rely on humanitarian efforts to feed themselves. Using the Integrated Food Security Phase Classification, the United Nations Relief and Works Agency (UNRWA) reports that “570,000 Gazans are classified as having food insecurity equivalent to famine levels of starvation.”^[1] In addition to long-term health problems for children, the lack of nutrition endangers pregnant and breastfeeding women whose babies will also be susceptible to health concerns. Considering this dire situation of displaced living, insufficient medical equipment and aid, and starvation, Gaza is experiencing a humanitarian crisis. And to compound the severity of this crisis, humanitarian aid is not reaching the entire population of Gazans, specifically at the southern Rafha border of Egypt and Gaza.

Insufficient Humanitarian Aid

A handful of humanitarian aid organizations are mobilizing their resources and workers to provide medical, food, and housing assistance for war civilians. Organizations include Doctors Without Borders, International Committee of Red Cross (ICRC), UNICEF, International Rescue Committee, UNRWA, and MedGlobal. Under the International Committee of the Red Cross Advisory Service, all parties in an armed conflict must “ensure that adequate medical care is provided to them as far as practicable and with the least possible delay.”^[1] Yet, current circumstances can only be described as inadequate and slow.

Multiple obstacles stand in the way of humanitarian workers reaching the Gaza Strip population. First, Egypt and Israel have coordinated the opening of the Rafah border since October 2023. However, Israel’s dual-use policy significantly restricts urgent goods. Goods are considered dual-use if they are classified for both civilian and military operations. A prominent example of a dual-use good is fuel. Israel fears the entry of fuel will supply Hamas military operations like firing rockets, “but fuel is also vital for civilian needs in the strip, particularly given the ongoing lack of electricity in the grid.”^[2] As mentioned in the previous section, fuel can repower medical facilities and alleviate water insecurity by providing electricity for desalination. With the enforcement of the dual-use policy, Gaza hospitals are struggling to remain functioning.

Fuel shortages also lead to frequent telecommunication blackouts. Gaza’s lack of access to the global internet leaves many human rights violations unreported. According to the United Nations Office for Coordination of Humanitarian Affairs (OCHA), airstrikes that are damaging Gaza’s core communications infrastructure “has brought the already challenging delivery of humanitarian assistance to a complete halt and is depriving people of life-saving information.”^[3] For instance, telecommunication blackouts are preventing first responders from quickly reaching emergency sites. At times, ambulances have resorted to hearing and following the sounds of explosive bombings without communication services, as described by the Palestinian Red Crescent Society. Data collection of dead persons are inaccurately reported and friends and family in and out of Gaza are barely able to communicate.

Airstrikes near hospitals and humanitarian aid shelters are also endangering the lives of medical, humanitarian aid, and media workers in the field as well. This past February, Israel’s army raid of Nasser hospital (the largest medical facility located in southern Gaza) killed 5 patients under intensive care and Doctors Without Borders “staff were forced to flee and leave patients behind.”^[1] Doctors Without Borders also reports that their “medical teams and patients have been forced to evacuate nine different healthcare facilities in the Gaza strip” since the beginning of the Israel-Hamas war.^[2] This constant relocation and displacement of war civilians and aid workers calls for a global readdressment of how humanitarian law plays a role in wartime conflict. As the world is in the Responsibility to Protect era, humanitarian aid organizations’ mission is to protect human security, which includes food and health security. Yet, it takes more than just aid organizations to prevent humanitarian crises.

How to Better Protect?

Considering an overview of recent and past wartime history in the past 100 years, the protection and value of healthcare for war victims and refugees has massively deteriorated. Ongoing conflicts in addition to the Israel-Hamas war include Russia and Ukraine, the internal Sudan conflict, Syrian Civil War, and oppressed ethnic communities in Myanmar. In each conflict, reports of attacks on healthcare facilities exist. Conflicts in history have demonstrated the targeting of hospitals and other medical aid facilities as a war tactic to deplete the other party of its resources and power. Israel has been justifying its airstrike attacks on Gaza hospitals by claiming that Hamas uses healthcare facilities as “command centers, hideouts and cover for their underground operations” while Hamas has denied these claims.^[1]

Attacks on healthcare personnel (specifically ethnic and female workers) and facilities are also reported. Attacks on medical transports include trends of looting equipment, destroying supply chains, and preventing ambulances to use sirens.^[2] This demobilization of medical aid is crippling to healthcare systems around the world. Solutions to mitigate this entanglement of healthcare and military targets include strengthening the relationships between humanitarian groups and conflict parties. Negotiating security is crucial in preventing attacks on medical facilities and transport. Clear neutrality in armed conflict should enable these services to provide urgently-needed assistance to non combatant civilians to their maximum ability and use of resources. In the case of the Israel-Hamas conflict, communication between medical units like Doctors Without Borders or the ICRC and defense forces should be clear on mobility coordination to ensure medical and humanitarian personnel are protected to aid the Gaza population.

In an interview with an emergency medicine physician and UC Berkeley professor Dr. Rohini Haar, she shares her research on the relationship between global health and human rights. She points to aggression towards health care workers in Democratic Republic of Congo as a starting place for intense investigation on healthcare in wartime. From this research: considering “all deaths in a war, ⅔ of them are actually indirect deaths, that is the term we use.” These indirect deaths are a result of “infectious diseases, lack of vaccination campaigns, cholera outbreaks, people dying” in absence of medicine. ^[3] Considering how telecommunication blackouts are immensely reducing medical aid, a thorough investigation on strengthening Gaza’s presence in digital networks could provide a revival of medical facility operations and increase access to medical aid. The damage of Gaza’s technological infrastructure severely limits its contact to the rest of the world and reviving its communication networks would save lives significantly. If this infrastructure is restored and protected, telemedicine could also play an important role in providing medical care to war civilians.

International Humanitarian Law

Under humanitarian law, it is understood that medical facilities are safe spaces during war conflict. Law for protection of healthcare workers and the wounded goes back to the 1864 Geneva Convention where it laid the foundation for humanitarian protection. At this convention, UN nation-state members agreed upon providing “specific protections for health care operations, seeking neutrality for all military medical personnel and hospitals.”^[1] Overtime, additional protocols were created to offer medical care to all prisoners of war, protection to medical transports, and develop war crime policies. But in spite of existing international humanitarian law, these doctrines leave room for flexible interpretation which brings healthcare under attack and ultimately disregards basic human rights, like access to shelter and food. The human rights advocacy community needs to play a more proactive role in political decision-making because human rights needs to be at the center of foreign policy.

In conclusion of this article, here are 3 main solutions that could alleviate the healthcare crisis in Gaza:

• Prioritize access to humanitarian aid in border policies to revitalize hospitals and feed the food-insecure.
• Negotiate security between medical units and conflict parties to prevent future attacks on medical transport and personnel.
• Restore Gaza’s communication infrastructure to increase access to medical and overall humanitarian assistance.

Humans as collateral damage in war continues to be a very real fact. And it is a worthwhile and urgent discussion to consider human collateral not as a tragedy of war, but a crime of war.