The Israeli military’s repeated, apparently unlawful attacks on medical facilities, personnel, and transport are further destroying the Gaza Strip’s healthcare system and should be investigated as war crimes, Human Rights Watch said today. Despite the Israeli military’s claims on November 5, 2023, of “Hamas’s cynical use of hospitals,” no evidence put forward would justify depriving hospitals and ambulances of their protected status under international humanitarian law.

The World Health Organization (WHO) has reported that at least 521 people, including 16 medical workers, have been killed in 137 “attacks on health care” in Gaza as of November 12. These attacks, alongside Israel’s decisions to cut off electricity and water and block humanitarian aid to Gaza, have severely impeded health care access. The United Nations found as of November 10 that two-thirds of primary care facilities and half of all hospitals in Gaza are not functioning at a time when medical personnel are dealing with unprecedented numbers of severely injured patients. Hospitals have run out of medicine and basic equipment, and doctors told Human Rights Watch that they were forced to operate without anesthesia and to use vinegar as an antiseptic.

“Israel’s repeated attacks damaging hospitals and harming healthcare workers, already hard hit by an unlawful blockade, have devastated Gaza’s healthcare infrastructure,” said A. Kayum Ahmed, special adviser on the right to health at Human Rights Watch. “The strikes on hospitals have killed hundreds of people and put many patients at grave risk because they’re unable to receive proper medical care.”

Human Rights Watch investigated attacks on or near the Indonesian Hospital, al-Ahli Hospital, the International Eye Care Center, the Turkish-Palestinian Friendship Hospital, and the al-Quds Hospital between October 7 and November 7. Human Rights Watch spoke by phone with two displaced people sheltering in hospitals and 16 healthcare workers and hospital officials in Gaza and analyzed and verified open-source data, including videos posted to social media and satellite imagery, as well as WHO databases.

Israeli forces struck the Indonesian Hospital multiple times between October 7 and October 28, killing at least two civilians. The International Eye Care Center was struck repeatedly and completely destroyed after a strike on October 10 or 11. Strikes hit the compound and vicinity of the Turkish-Palestinian Friendship Hospital on October 30 and 31. Damage to the hospital as well as a lack of fuel for hospital generators resulted in its closure on November 1. Repeated Israeli strikes damaged the al-Quds Hospital and injured a man and child out front. Israeli forces on several occasions struck well-marked ambulances, killing and wounding at least a dozen people in one incident on November 3, including children, outside al-Shifa hospital.

These ongoing attacks are not isolated. Israeli forces have also carried out scores of strikes damaging several other hospitals across Gaza. WHO reported that as of November 10, 18 out of 36 hospitals and 46 out of 72 primary care clinics were forced to shut down. The forced closure of these facilities stems from damage caused by attacks as well as the lack of electricity and fuel.

Health workers at Gaza’s hospitals told Human Rights Watch they are dealing with unprecedented numbers of injured patients. Additionally, thousands of internally displaced people sheltering at hospitals have been put at risk, facing shortages of food and medicine. Gaza’s hospitals have been forced to address these issues with shortages of medical staff, some of whom have been killed or injured outside their work.

A doctor at Nasser Medical Center said: “At 3 a.m. I dealt with a 60-year-old woman with a cut wound in her head. I can’t make a suture to heal her wound—no gloves, no equipment—so we have to use unsterile techniques.”

Hospitals and other medical facilities are civilian objects that have special protections under international humanitarian law, or the laws of war. Hospitals only lose their protection from attack if they are being used to commit “acts harmful to the enemy,” and after a required warning. Even if military forces unlawfully use a hospital to store weapons or encamp able-bodied combatants, the attacking force must issue a warning to cease this misuse, set a reasonable time limit for it to end, and lawfully attack only after such a warning has gone unheeded. Ordering patients, medical staff, and others to evacuate a hospital should only be used as a last resort. Medical personnel need to be protected and permitted to do their work.

All warring parties must take constant care to minimize harm to civilians. Attacks on hospitals being used to commit “acts harmful to the enemy” are still unlawful if indiscriminate or disproportionate. The use of explosive weapons in densely populated areas heightens the risk of indiscriminate attacks. Attacks in which the anticipated loss of civilian life and property are excessive compared with the concrete and direct military gain are disproportionate. Concerns about disproportionate attacks are magnified with respect to hospitals, since even the threat of an attack or minor damage can have massive life-or-death implications for patients and their caregivers.

The Israeli military on October 27 claimed that “Hamas uses hospitals as terror infrastructures,” publishing footage alleging that Hamas was operating from Gaza’s largest hospital, al-Shifa. Israel also alleged that Hamas was using the Indonesian Hospital to hide an underground command and control center and that they had deployed a rocket launchpad 75 meters from the hospital.

These claims are contested. Human Rights Watch has not been able to corroborate them, nor seen any information that would justify attacks on Gaza hospitals. When a journalist at a news conference showing video footage of damage to the Qatar Hospital sought additional information to verify voice recordings and images presented, the Israeli spokesperson said, “our strikes are based on intelligence.” Even if accurate, Israel has not demonstrated that the ensuing hospital attacks were proportionate.

Israel’s general evacuation order on October 13 to 22 hospitals in northern Gaza was not an effective warning because it did not take into account the specific requirements for hospitals, including providing for the safety of patients and medical personnel. The sweeping nature of the order and the impossibility of safe compliance, given that there is no reliably secure way to flee or safe place to go in Gaza, also raised concerns that the purpose was not to protect civilians, but to terrify them into leaving. The WHO director general has said that “it’s impossible to evacuate hospitals full of patients without endangering their lives.”

The Israeli government should immediately end unlawful attacks on hospitals, ambulances, and other civilian objects, as well as its total blockade of the Gaza Strip, which amounts to the war crime of collective punishment, Human Rights Watch said. Hamas and other Palestinian armed groups need to take all feasible precautions to protect civilians under their control from the effects of attacks and not use civilians as “human shields.”

The Independent International Commission of Inquiry on the Occupied Palestinian Territory, including East Jerusalem, and Israel should investigate apparently unlawful Israeli attacks on healthcare infrastructure in Gaza.

The International Criminal Court prosecutor has jurisdiction over the current hostilities between Israel and Palestinian armed groups that covers unlawful conduct by all parties. The ICC’s Rome Statuteprohibits as a war crime “[i]ntentionally directing attacks against … medical units and transport.” Israeli and Palestinian officials should cooperate with the commission and the ICC in their work, Human Rights Watch said.

The United States, United Kingdom, Canada, Germany, and other countries should suspend military assistance and arms sales to Israel as long as its forces continue to commit widespread, serious abuses amounting to war crimes against Palestinian civilians with impunity. All governments should demand that Israel restore the flow of electricity and water to Gaza and allow in fuel and humanitarian aid, ensuring that water, food, and medication reach Gaza’s civilian population.

“Israel’s broad-based attack on Gaza’s healthcare system is an attack on the sick and the injured, on babies in incubators, on pregnant people, on cancer patients,” Ahmed said. “These actions need to be investigated as war crimes.”