The violent attacks and hostage-taking in Israel on 7 October 2023, and the subsequent and ongoing military onslaught in Gaza, West Bank and military attacks in that region add to conflicts in Ukraine, Yemen, eastern DRC, Sudan, Myanmar and other countries. Yet the intensity in Gaza has been a shock globally, including in our region. For example, WHO reports the number of children killed in the three weeks following 7 October to have surpassed the annual number of children killed in all conflict zones since 2019. As a health network, we focus this statement only on the health dimensions of the situation reported in United Nations evidence, that is the attacks on health personnel, the destruction of health services and the denial of medicines, health technologies, water and food. We write this to raise attention to whether we can better and more rapidly fulfill our duties to protect these health issues in conflict, in Gaza and elsewhere.

The major United Nations International Covenants on human rights (the ICCPR ratified by 172 countries and ICESR ratified by 171 countries) protect the right to life and to health. In situations of conflict, the Geneva and Hague Conventions provide further that there should be ‘no obstacle to humanitarian activities’, and that the wounded and sick should ‘be respected and protected in all circumstances’. Access to health services are vital to provide this respect and protection, and these conventions state that hospital and medical facilities should not be attacked. The only exception to the latter is if civilian hospitals are actively used to commit ‘acts harmful to the enemy’.

That accessible, well equipped health care and humanitarian relief is needed in Gaza is unquestionable. While attacks have taken place in Israel, Gaza and other areas, the scale of the situation in Gaza is extreme. Between October 7 and 19 January, 24 762 people in Gaza were reported by Reliefweb and UN sources to have been killed, including over 7,729 children, with a further 62 108 injured, and over 7 780 others missing, presumed dead under rubble. Teresa Zakaria, a World Health Organisation (WHO) Health Emergencies official, notes the largest proportion of recorded fatalities to be children (45%) and women (30%).

United Nations (UN) reports provide evidence of the mounting deprivations of the basics for life and health. A UNICEF official warned in January 2024 that “silent, slow deaths caused by hunger and thirst risk surpassing those violent deaths already caused by Israeli bombs and missiles.” In mid-January 2024, WHO reported the entire population of Gaza – roughly 2.2 million people- to be ‘in crisis or worse levels of acute food insecurity’, with 1.9 million people displaced from their homes, and over 1.4 million staying in overcrowded shelters. The conflict has damaged or destroyed essential water, sanitation and health infrastructure, with the World Food Programme reporting in December 2023 only 1.5 to 1.8 litres of clean water to be available per person per day, for all uses, below even the daily ‘survival threshold’ of 3 litres. Beyond the mental ill health impact of military conflict on civilians, WHO report soaring rates of infectious disease, with a 25-fold escalation in case rates of diarrhoea, and rising cases of upper respiratory infection, meningitis, scabies, jaundice and chickenpox. Hunger increases the risk of mortality from these conditions. The effects are not only short-term. UNICEF estimated 1,000 children having lost one or both legs during the conflict and a combination of disease and a 30% rise in wasting that risks survival and their longer-term development.

WHO stated last December: “The people of Gaza, who have already suffered enough, now face death from starvation and diseases that could be easily treated with a functioning health system. This must stop”.

Yet access to health services across Gaza has also plummeted with the destruction of health services. As reported by UNICEF by January 2024, there had been 590 direct attacks on healthcare in Gaza and West Bank since the war began, with 291 ambulances damaged, including those marked with the Red Cross or Red Crescent emblem. Missiles have also been fired on health facilities in Israel, with the WHO Surveillance system for attacks on health care reporting on 31 January 2024 that there had been 64 attacks on health facilities in Israel, 18 impacting on facilities, 38 impacting personnel and 13 impacting patients. However, the attacks in Gaza have been significantly more widespread and destructive of health services. By last December, WHO reported more than 238 attacks on healthcare in Gaza alone, damaging or destroying over 61 hospitals and other healthcare facilities. For example, Al-Indonesi hospital was reported by a UN official last December to have been bombed 35 times since 28 October. The military attacks have targeted hospital generators, hospital solar panels, and life-saving equipment, such as oxygen stations and water tanks. As a result, only 13 out of 36 hospitals and 18 out of 72 healthcare centres are reported to still be functioning — some of them barely — despite the overwhelming need for these services. In December last year, WHO reported 21of Gaza’s 36 hospitals to be closed, and of the remaining 15, eleven to be only partially functional and four ‘minimally functional’. Those that are open are operating at multiple times their bed capacity. They lack fuel supplies, food and clean water, which with accumulating medical waste raises a public health risk for patients and the thousands of displaced persons sheltering in hospital grounds. Direct bombing of health services has endangered patients and those sheltering in hospital grounds, with WHO reporting in December 2023 that at least 570 Palestinians have been killed at hospitals and healthcare centres in Gaza, and a further 746 injured by Israeli military strikes or snipers.

As noted earlier, international law does not protect health services that are actively used to commit acts of war. In January 2024, Israeli authorities alleged in its case in the International Court of Justice that hospitals in Gaza were used as sites of military action, with militants using some hospitals to retreat to, to hold hostages in, or to fire on Israeli forces. In the same month a WHO official observed that there was no evidence that hospitals in the Gaza Strip were being used for purposes other than providing healthcare. The consequence remains that the wounded and sick are left without respect and protection, in contrast to international norms.
Many health workers in Gaza did not leave their patients and continued to serve despite the risk to their own lives. In December 2023, UNICEF reported over 311 doctors, nurses and other health workers, including doctors and ambulance drivers killed on duty, while WHO has reported medics and first responders to have been repeatedly detained by Israeli forces, many of these detained incommunicado at unknown locations. Tlaleng Mofokeng, UN Special Rapporteur on the right to health stated, “We are in the darkest time for the right to health in our lifetimes,” She said. “For people to have access to quality healthcare, they must have access to healthcare workers, and those healthcare workers must be safe and free to provide care.” “We bear witness to a shameful war on healthcare workers”.

Those injured in attacks find insufficient staff and resources for adequate care, raising the risk of infected, necrotic or gangrenous wounds, and deaths from what should be treatable conditions. However, the denial of health care does not only affect those injured in conflict. It affects those needing other forms of care. Patients have to cross long distances in dangerous conditions to find an open facility. Existing triage criteria in emergency departments have to give precedence to war injuries over non-emergency cases, undermining other forms of care. WHO reported in November 2023 an estimated 5,500 Palestinian women in Gaza giving birth each month in unsafe conditions, often with no medical assistance or clean water. UN News report operations, including amputations and caesarean sections, taking place without anaesthetic.

There have been efforts to respond. Since the start of the hostilities, WHO, other UN agencies and partners have been supporting the health system and humanitarian relief in Gaza with high-risk missions to deliver medical equipment and supplies, medicines, fuel, coordination of emergency medical teams, and disease surveillance. Agencies have also delivered food and water to people inside Gaza. The UN estimated in November 2023 that the Gaza population required at least 500 humanitarian aid trucks every day, a need that is estimated to have doubled recently, given the prolonged attacks, destruction, and interruption of adequate aid distribution. At the same time, UN OCHA report that the response capacity is hindered by damaged roads, delays at checkpoints ‘security risks, mobility constraints, delays, denials and a constant risk of distribution in a conflict zone where aid workers have been killed and some convoys shot at.

The current situation worsens a health system already weakened by the 16-year-long blockade of Gaza prior to October 7, with restrictions since 2007 at Israel-controlled crossing points of supplies and services, and on access to medical care outside Gaza. Already by 2020, a UN Special Rapporteur described the impact of this blockade as having turned Gaza “from a low-income society with modest but growing export ties to the regional and international economy to an impoverished ghetto with a decimated economy and a collapsing social service system”.

The long-term and immediate situation signals that despite the global treaties protecting health, healthcare and human dignity in conflict zones, we do not yet have the measures to operationalise them before significant harm occurs. In December, 2023 WHO’s Executive Board adopted by consensus a draft resolution on “Health Conditions in the Occupied Palestinian Territory” calling for “immediate, sustained and unimpeded passage of humanitarian relief, including the access of medical personnel,” and for “all parties to armed conflict to comply fully with the obligations applicable to them under international humanitarian law related to the protection of civilians in armed conflict and medical personnel.” The consensus adoption was noted to reflect ‘the importance of health as a universal priority, in all circumstances, and the role of healthcare and humanitarianism in building bridges to peace, even in the most difficult of situations’.

The efforts of UN and other agency personnel to deliver support and the WHO reports and engagement in various forums have been important and valued, including to document and report violations. The recent South African Case at the International Court of Justice (ICJ) has triggered provisional legal measures to protect access to adequate food and water; medical care; hygiene; sanitation; and other forms of humanitarian relief. Israel asserted at the ICJ that it is eager to expand humanitarian aid to the fullest extent of its capacity; and to support rather than interfere with the work of medical personnel. However, attacks on and deaths of civilians have continued since the ICJ hearing at a rate of 145 people per day. On 17 January, the Jordanian field hospital in Khan Yunis was targeted during an Israeli bombing, injuring one of the health crews and a person receiving treatment in the intensive care unit; and lighting bombs were dropped over the Nasser Medical Complex in Khan Yunis.

The most obvious measure for Gaza’s health system and population is that called for by the UN Secretary General, the WHO and other UN agencies and countries, an immediate ‘humanitarian’ ceasefire and work to stop the war, safely provide humanitarian relief and rebuild key infrastructure and services. As WHO Director-General Dr Tedros Adhanom Ghebreyesus said on the adoption of the WHO Executive Board resolution “Without a ceasefire, there is no peace. And without peace, there is no health.”

However, we should not stop there. International norms are now easier to monitor globally, and within regions and countries, so lack of information cannot be a cause of inaction. However, it appears that we may draw little comfort from the specific protection of civilian health, health services and health workers in conflict zones in international conventions, if they can be breached over a sustained period with impunity, and without resolution, including from a paralysed response to human security at the level of the UN Security Council. Responses are rightly now preoccupied with ending the immediate traumas. But the situation in Gaza also sends a strong signal that, in moving forward, we must proactively strengthen the domestic and regional policy articulation of and preparedness to apply international norms on protection of health and health care in conflict in all regions globally. We need to profile and strengthen the level and speed of response of the national and international systems that ensure compliance with these norms, and where needed penalty and remedy for breaches, when this concerns access to health services, humanitarian activities and protection of the wounded and sick in conflict zones.