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Whenever the Israeli public is called upon to discuss the fate of the Gaza Strip, the debate tends to focus on the question of who will control the territory after the war. In recent weeks, this debate, too, seems to have been sidelined by the escalating war on Lebanon and the Iranian threat.
Gaza’s fate, however, is not limited to questions of sovereignty or control, but to the very existence of life. Indeed, two recent publications that focused on Gaza’s health system sharply illustrate how much the current catastrophe challenges the very possibility of sustaining life in the territory.
At the end of September, the Palestinian Ministry of Health in Gaza issued a document that, for the first time, comprehensively details the damage to hospitals in the Strip over a year of war. The novelty of the report is not in the new information it brings, but rather in the aggregation of over 100 incidents that were reported in real time in the international and Arab media, as well as in periodic reports by international humanitarian organizations, into one document. It thus pieces together the gradual disintegration of Gaza’s health system, the direct and indirect causes of which are the responsibility of Israel and its army.
Meanwhile, on Oct. 2, 99 American medical professionals who volunteered in Gaza during the war for a cumulative 254 weeks issued a public letter to U.S. President Joe Biden and Vice President Kamala Harris, presenting a stark picture of the health of the civilian population in the Strip. These professionals — some with extensive experience providing medical relief in war zones and after natural disasters — said that the situation in Gaza was much worse than anything they had encountered before, including in Afghanistan or Ukraine.
A few days after the letter’s publication, we spoke separately with three of the signatories to get more detailed, first-hand accounts of the state of Gaza’s health system. Their insights are shared here alongside those of the documents above.
Easing suffering before death
The picture that emerges from the two documents and our conversations with doctors shows the fatal blow dealt to Gaza’s entire health system and infrastructure.
Only a few echoes of this disintegration reach the Israeli media; in fact, the absence of these reports from the Israeli public discourse creates the impression inside Israel that the early warnings of famine and epidemics in Gaza have not materialized. Moreover, the only number that is discussed is that of fatalities of Israeli attacks (over 43,061 Palestinians as of writing) — a number that excludes deaths from disease, starvation, and the poor health of the population after a year of war.
An examination of the data and testimonies, however, reveals the scope of the harm to the general Palestinian population, and particularly the lives of the most vulnerable — infants and toddlers, pregnant women, the elderly, and the chronically ill.
For example, the medical professionals who signed the letter to Biden and Harris estimate that it is likely that the death toll in Gaza since the beginning of the war exceeds 118,908. The letter explicitly states that, with marginal exceptions, the entire population of Gaza is sick and/or injured, and almost all children under the age of 5 whom the doctors encountered suffered from coughing and diarrhea.
In a survey conducted by Dr. Feroze Sidhwa, an American surgeon who returned from Gaza, in conjunction with The New York Times, 63 of 65 American health care workers who volunteered in Gaza described severe malnutrition among patients, Palestinian health workers, and the general population. In addition, 52 medical professionals described near-universal mental distress among young children, noting that they had seen some who were suicidal or hoping to die. One of the nurses said that the children did not respond to pain, even while they were being stitched up after being wounded.
The doctors’ letter states that all medical personnel who worked in Gaza’s emergency rooms, intensive care units (ICU), or surgical wards said that they regularly treated small children who were shot in the head or chest. Dr. Mimi Syed, an emergency physician from Seattle who returned from Gaza in September, told us that while working in the ICU of Nasser Hospital in Khan Younis such injuries were very common, and that in some cases, all she and the staff could do was to ease their patients’ suffering and let them die. In her words:
The majority of my patients were anywhere from six months old to early 20s. Most of them were on the lower end of that spectrum. There was a day where we had nothing but gunshot wounds to the head reported to be quadcopters by witnesses. And there was nothing to do for most of them. They were in palliative care because their injuries were so devastating that we had to just let them die. There must’ve been about eight patients that day in our Trauma Bay.
In Dr. Sidhwa’s survey, 44 medical professionals reported that they had seen multiple such cases during their stay in Gaza.
An intentional pattern
The medical professionals’ letter places the blame for the systematic and deliberate destruction of Gaza’s health system on Israel. Indeed, considering all the information regarding the state of the Strip’s hospitals, one clearly sees an intentional pattern. Hospitals and clinics were repeatedly hit by aerial bombardment; have suffered from a shortage of electricity and diesel fuel for generators; have been encircled by tanks; saw their medical staff and patients expelled as part of the evacuation of an entire area; and in some cases, were turned into military bases.
As of late October, 20 of the 36 hospitals in Gaza were out of service, while 16 were only partially functional. Of the 11 field hospitals, half are only partially functional. The number of hospital beds across the Strip dropped by 75 percent (from approximately 3,400 at the beginning of the war to around 1,200 in late September), just as the need for them increased due to the large number of wounded, the severe shortage of medicines and medical equipment, and the near-universal spread of infectious diseases.
The sequence of data and dates provided by the Gaza Health Ministry’s report indicates a series of bombings in the first two weeks of the war that shut down several hospitals, mainly in the northern Strip; it also notes the takeover of hospital compounds in November, followed by the de facto shutdown of all hospitals in northern Gaza and most hospitals in Gaza City.
Al-Ahli Arab Hospital made headlines in mid-October 2023 following an explosion that killed hundreds of men, women, and children who found shelter there. Although the question of responsibility for the blast remains disputed, the incident and the ensuing debates set a precedent by normalizing attacks on hospitals in an unprecedented manner.
During November 2023 alone, 12 of Gaza’s 36 hospitals were put out of service temporarily or permanently. Al-Shifa Hospital was raided twice by the army, in November 2023 and March 2024. While Israeli media chose to focus on a Hamas tunnel and a number of militants in Al-Shifa compound, international media reported on the massive destruction to the hospital and the severe damage to its ability to function, resulting in its complete destruction in the second raid. The second raid also led to the discovery of mass graves, some of which had been dug by Gazans during an earlier siege of the hospital, and some of which were dug while the military took over the compound.
Another wave of attacks on hospitals in the southern Gaza Strip followed the takeover of the city of Rafah in May 2024. In some cases, staff and patients were forced to leave hospital compounds, while others were shelled or bombed. Some hospitals were completely destroyed or converted for use as military outposts.
In early October 2024, the military ordered three hospitals in northern Gaza to evacuate once more as part of a broader move to expel the entire civilian population from the north (the so-called “Generals’ Plan”). This raised the alarm among at least 38 humanitarian organizations, which highlighted the harm caused to the medical system, and the UN Human Rights Office, which called the situation “desperate.” Israeli commentators have similarly expressed alarm toward what appears to be ethnic cleansing.
‘Either the baby dies because of no ventilator, or because of infection’
A series of monthly publications by the Palestinian Health Ministry, as well as periodic reports by the World Health Organization (WHO) and the UN Office for the Coordination of Humanitarian Affairs (OCHA), further present the long-term consequences of the destruction of medical services in the Strip.
According to the UN, 1,047 Palestinian medical personnel have been killed and 310 have been arrested during the war — a reality that places an even greater strain on local medical teams. The medical professionals’ letter states that their local Palestinian colleagues were aware that their work as healthcare providers had marked them as targets, and that many of them were arrested, abused, and taken to detention facilities in Israel before being returned to Gaza by the military. Many told their American colleagues that they were simply waiting to die.
Many medical staff have not received their salaries for months. A great number of them have lost family members, yet continue to come to work. Many live in tents near the hospitals, or walk daily — sometimes for hours — from the family tent to the hospitals.
Thousands of the over 100,000 wounded have had their limbs amputated, at a time in which the Gaza Strip does not have crutches or wheelchairs, let alone prosthetic limbs, to serve amputees. Meanwhile, children who are injured require a series of surgeries that they cannot receive in the current state of Gaza’s health system. All of these findings were backed up by the medical professionals’ letter and by eyewitness accounts we collected.
The destruction of Gaza’s civilian infrastructure has drastic implications for its ability to maintain a functioning health system. Of the 16 operating hospitals, only four have a full supply of water and sewage services, while only two have regular electricity.
The consequences are obvious: without electricity, it is impossible to operate oxygen machines or keep medicines refrigerated. Without basic sanitation, the danger lies in contracting deadly diseases even inside the hospital. The medical professionals’ letter states that they have found cases of jaundice in almost all the hospital rooms where they volunteered, and among the Gaza medical staff.
Due to severe shortages of soap and detergents throughout the Strip — in Dr. Sidhwa’s survey, 64 out of 65 respondents said that even the most basic medical equipment, such as soap and gloves, were usually unavailable — the surgical environment could not be disinfected, leading to high death rates from infections.
In a conversation with us, pediatrician Dr. Aman Odeh, who worked in Rafah during March, before the Rafah crossing to Egypt was closed, testified that soap bottles in the operating room contained only a small amount of liquid soap that had been diluted with water. In the absence of detergents, the ventilator tube in the neonatal ward was not disinfected between uses, leading to the spread of infections and mortality among premature babies. Dr. Odeh describes the scenes she saw:
There was a newborn in the neonatal ICU who was deteriorating very quickly no matter what we tried. We tried the strongest antibiotics, but we were not able to control the infection. That was a day when we were able to get a blood culture bottle from another place at the hospital. After the baby passed away, they were able to identify what type of bacteria it was. It was a multidrug resistant bacteria. But then the next day, other babies were showing similar patterns. We didn’t have hand sanitizer. The soap bottle was a tiny bit of soap and old water. We didn’t have gloves. The infections were spreading so quickly.
A baby who was very, very sick, needed to be on a ventilator. After the baby passed away, what are we going to do with that ventilator? There is no way to sanitize the ventilator and get rid of that multidrug-resistant bacteria. We also didn’t have tubing to change when we used the ventilator for another baby. So there is a very big chance that you’re going to spread the infection to other babies: so either the baby dies because there is no ventilator or the baby dies because of the bacterial infection. Your options were tragically limited.
Dr. Syed told us that while she was in Gaza, a shipment of soap arrived, but the price of a small bottle rose to $40. One nurse said she saw more maggots in wounds in one day in Gaza than she had seen in her entire career as a wound specialist.
Lethal combinations
The medical professionals’ letter notes that a high percentage of the incisions in their surgeries were contaminated. Dr. Thalia Pachiyannakis, an obstetrician-gynecologist from Indiana, told us that hospitals cut down on their air conditioning to save fuel, resulting in her performing operations at Nasser Hospital at 40° Celsius (104°Fahrenheit), so that sweat from her forehead and the foreheads of the other medical personnel dripped into the wounds of the patients they were operating on.
The letter indicates that the surgeries, including cesarean sections, were performed without anesthesia or pain relief. Afterward, women were given only paracetamol to treat their pain.
Dr. Pachiyannakis also spoke about the lack of clean water for herself as an international volunteer, which caused her and the rest of the medical staff to become ill. “We were also very sick. You get sick with diarrhea, then you get better, then you get it again, and you’re vomiting. Once I was vomiting and had diarrhea at the same time,” she told us.
For young children born malnourished and who are fed formula made with contaminated water, this condition becomes life-threatening; according to the medical professionals’ letter, many have died as a result. Twenty-five medical professionals interviewed for the survey said they saw babies who had been born healthy return to hospitals and die of dehydration, malnutrition, or infections.
Dr. Odeh testified that other babies, whose mothers were unable to breastfeed them due to malnutrition and did not receive adequate nutrition due to a lack of formula and lack of clean water, received an infusion at the hospital but were returned home with the same condition that led to their hospitalization.
The numerous testimonies emphasize the chronic lack of equipment inside Gaza. The three doctors we spoke with testified that the Israeli military forbade them from bringing medical equipment they had purchased themselves into Gaza. In the delivery rooms where Dr. Odeh worked there was only one ventilator, while in the delivery rooms where Dr. Pachiyannakis worked, there was no refrigerator, which left the food contaminated.
There’s no clean water, no pain medicine for women in labor, the labor beds are broken. There’s only one warmer for the newborns, so when they’re born they’re all put together in one warmer. And there’s only one machine for monitoring a baby, so if a baby is having bad heart tones, you cannot pick it up because there’s only one working machine. So there would be fetal deaths.
One of the nurses reported that nearly all of the new children admitted during her time in Gaza died, and that these deaths could have been prevented with proper nutrition, basic disinfectants, and adequate supplies.
As of the end of September, only 17 of the 113 dialysis units that were present in the northern Gaza Strip on the eve of the war remained operational, compared to 72 out of 178 in the south.
In their letter, the medical professionals worried that thousands have already died from the lethal combination of malnutrition, disease, and the inability to receive proper treatment, and that tens of thousands more could die in the coming months due to winter conditions in Gaza. Most of the dead, they warn, will be small children whose immune systems are weaker than those of adults.
Unconvincing legal claims
In a recent policy paper for the Institute for Palestine Studies, the scholars Nicola Perugini and Neve Gordon argued that Israel very broadly interprets the reservation in international law regarding the protection of hospitals. According to international law, hospitals can be attacked only if combat activity is carried out from within the hospital itself, and provided that the attack is proportionate and done out of genuine military necessity, and provided that the combat force protects the lives of non-combatants.
Testimonies describing Israel’s attacks on hospitals, the expulsion of all their inhabitants, and the exposure of mass graves clearly indicate non-compliance with these legal conditions. These, in turn, connect to the larger picture of the nature of the military operation in the Gaza Strip and the dire humanitarian situation arising from it, many details of which have been published on +972.
Perugini and Gordon propose an amendment to international law that would prohibit attacks on hospitals under any circumstances. The widespread impact on all hospitals in Gaza, however, cannot wait for such a change to unfold. And in light of the abundant evidence accumulated over the past year, Israel’s arguments for meeting the reservations set forth in international legal conventions are not convincing.
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An independent UN commission of inquiry on damage to the Strip’s health infrastructure published in September found that Israel’s actions are part of a deliberate policy that constitutes a crime against humanity, including in the form of extermination and torture. The report’s authors found no support for most of Israel’s claims about Hamas’ military use of hospitals, noting that Israel did not pass on information to the report’s authors, despite requesting such information nine times.
The destruction of the health system presents a bleak picture of Gaza’s present, let alone its future. A war that destroys hospitals and does not allow for the establishment of a suitable alternative is a war against a civilian population, one that is now plagued by disease and starvation. Any discussion of the war in the present or the “day after” must therefore take an honest and direct look at the immediate consequences of Israel’s policies for its victims.
A version of this article first appeared in Hebrew on Local Call. Read it here.