Devastation in Gaza

The war in Gaza is a humanitarian crisis and the latest example of healthcare workers being targeted in conflicts. Bette Browne reports

 Many thousands have been killed since the Israel-Hamas war began in October 2023. Aid officials say thousands more are buried under the rubble of bombed-out homes and buildings across Gaza. The casualties to date include at least 300 healthcare workers.

Israel began bombarding the Palestinian territory after Hamas killed 1,200 Israelis and took more than 200 people captive. The level of death and destruction since then is without parallel in modern warfare, according to some experts. Oxfam stated in January that 250 Gazans are dying each day under Israeli attacks.

United Nations (UN) Secretary-General Mr Antonio Guterres said in a statement on 21 January: “Israel’s military operations have spread mass destruction and killed civilians on a scale unprecedented during my time as Secretary-General.”

The war has caused more destruction, proportionally, than the Allied bombing of Germany in World War II, according to Mr Robert Pape, a US military historian.

Between 1942 and 1945, the Allies attacked 51 large German cities and towns, which destroyed about 40-to-50 per cent of their urban areas, Mr Pape told the Associated Press. This amounted to 10 per cent of buildings across Germany. However, across Gaza the proportion is over 33 per cent.

“Gaza is one of the most intense civilian punishment campaigns in history,” said Mr Pape. “It now sits comfortably in the top quartile of the most devastating bombing campaigns ever.”

It could take decades for Gaza’s economy to return to its pre-war size if the conflict was to cease immediately, the UN Conference on Trade and Development said in a report published on 1 February.

Children

The number of children who have died in the conflict, in particular, has provoked significant widespread concern.

“There is nowhere safe for Gaza’s one million children to turn,” UNICEF Executive Director Ms Catherine Russell told Le Monde after a visit to Gaza in November 2023. “The parties to the conflict are committing grave violations against children. These include killing, maiming, abductions, attacks on schools and hospitals, and the denial of humanitarian access – all of which UNICEF condemns.”

In addition to deaths, more than 1,000 children have had their legs amputated, without anaesthetic, UNICEF spokesman Mr James Elder said on 19 December at a press briefing.

The healthcare system in Gaza, already crippled by the 17-year-long Israeli blockade, is facing severe shortages of medical equipment and supplies. Diseases are spreading and so is hunger.

Gazans currently constitute 80 per cent of all people facing famine or catastrophic hunger worldwide, marking an unparalleled humanitarian crisis, according to the UN.

“Every single person in Gaza is hungry, a quarter of the population are starving and struggling to find food and drinkable water, and famine is imminent,” the UN Office of the High Commissioner for Human Rights said on 16 January.

The Director of the World Health Organisation (WHO) Emergencies Programme, Dr Michael Ryan, told a press conference on 1 February that the population of Gaza is “starving to death” due to constraints imposed on humanitarian aid. “And if you mix a lack of nutrition with overcrowding and exposure to cold through lack of shelter… you can create conditions for massive epidemics, particularly in children. And we’re seeing them,” he said.

Hospitals

According to the WHO, there have been more than 200 Israeli attacks on hospitals and ambulances since October last year.

Israel accuses Hamas militants in Gaza of operating inside and underneath hospitals and using them for military operations, including as command centres and weapons stores. Hamas, along with medical personnel in hospitals, has denied these claims. It should also be noted that while international law gives hospitals special protection during war, hospitals can lose those protections if combatants use them to hide fighters or store weapons. WHO Director-General Dr Tedros Adhanom Ghebreyesus wrote on a social media post on 7 January: “It is inconceivable that this most essential need – the protection of healthcare – is not assured.”

Medical experts from Trócaire’s partner Medical Aid for Palestinians have reported the shocking nature of injuries presenting in hospitals.

“The injuries we’re witnessing are predominantly blast injuries with shrapnel wounds all over the body,” Prof Nick Maynard, a senior surgeon from Oxford University Hospital, said in an article on the Trócaire website.

“Most are to the limbs, and multiple adults and children and babies are coming in with traumatic amputations of arms and legs. We’ve seen small children with the most horrible facial burns. Every square inch of the hospital – the halls, the staircases, the reception areas, the wards – are covered with people lying on the ground.”

Mr Jacob Burns, Médecins Sans Frontières (MSF) project coordinator, described hospital conditions after arriving in Gaza on 17 December 2023: “When people are coming in, the staff are literally kneeling in blood on the floor to try to save the life of a person, putting in a chest tube, even intubating on the floor, which is just really, really extreme.”

Continual bombardment, power outages, and shortages of essential medical supplies and food have left nearly every hospital out of service, with evidence of repeated attacks on and in the vicinity of medical facilities despite the presence of doctors, patients, and civilians inside, according to a CNN analysis on 12 January.

“At least 20 out of 22 hospitals identified by CNN in northern Gaza were damaged or destroyed in the first two months of the war, according to a review of 45 satellite images and around 400 videos from the ground, as well as interviews with doctors, eyewitnesses, and humanitarian organisations,” said the CNN report.

“Fourteen were directly hit, based on the evidence collected and verified by CNN and analysed by experts.”

The doctors and nurses left struggling to help survivors amid the deadly daily violence have become heroes to many. “These men and women should be recognised for their heroism,” Dr Tarek Loubani, a Canadian/Palestinian emergency physician, told America’s National Public Radio in an interview shortly after the war began.

UNRWA

At a time of greatest need for the people, the main UN relief agency in Gaza, the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), faced unrest after Israel accused some of its staff of involvement in Hamas’ 7 October 2023 attacks. Of the 12 people implicated, UNRWA immediately identified and terminated the contracts of 10. The remaining two employees are confirmed dead. An investigation has also been launched by the UN’s Office of Internal Oversight Services. It should also be noted, according to the agency, that 152 UNRWA workers have been killed in Gaza since the war began.

The US State Department on 26 January said it had “temporarily paused additional funding” to the agency because of the allegations. A few days later, on 29 January, however, US Secretary of State Mr Anthony Blinken made a point of acknowledging UNRWA’s contribution in Gaza. “UNRWA has played and continues to play an absolutely indispensable role in trying to make sure that men, women, and children who so desperately need assistance in Gaza actually get it,” Mr Blinken told reporters. “That only underscores the importance of UNRWA tackling this as quickly as effectively and as thoroughly as possible.”

By then a number of other countries, including the UK, Canada, Australia, and Germany, had also suspended aid to UNRWA. However, some other countries, including Ireland, said they would continue funding. Tánaiste and Foreign Affairs Minister Micheál Martin said in a social media post on 27 January that he was confident the allegations would be investigated thoroughly, adding: “(Ireland) has no plans to suspend funding for UNRWA’s vital Gaza work. UNRWA’s 13,000 employees provide life-saving assistance to 2.3 million people and at incredible personal cost – with over 100 staff killed in the last four months.”

Norway’s government also announced it would continue funding.

The need for continuing support was emphasised by MSF which, on 26 January, warned that Nasser Hospital was nearing collapse. Ms Guillemette Thomas, MSF medical coordinator in Palestine, said: “With Nasser and the European Gaza Hospital almost inaccessible, there is no longer a healthcare system in Gaza. These systematic attacks against healthcare are unacceptable and must end now so that the wounded can get the care they need. The entire health system has been rendered inoperative.”

Healthcare casualties in other conflicts

It is not unusual, of course, in the history of warfare that doctors and aid workers are killed. However, in modern times it is increasingly becoming the norm in many conflicts. In Ukraine, according to WHO data, for example, Russia attacked health facilities, ambulances, and health workers more than 1,000 times in the first 18 months of that war, which began in 2022 and is now entering its third year. Ukraine’s  Ministry of Health reported in 2022 that 144 hospitals had been destroyed.

“Attacks on healthcare are a violation of international humanitarian law,” Dr Jarno Habicht, WHO representative in Ukraine, said in Kiev in May 2023. “The fact that the health system in Ukraine continues to operate amid such circumstances is a testament to the heroic dedication of healthcare workers.”

A report in February 2023 by the International Bar Association’s eyeWitness to Atrocities, along with Insecurity Insight, Media Initiative for Human Rights, Physicians for Human Rights, and Ukrainian Healthcare Centre, documented the scale of attacks on Ukraine’s healthcare centres and staff by Russian forces in 2022.

In just the first two weeks of the invasion, four-to-five hospitals and clinics were attacked every day. By 31 December of that year, 707 documented assaults had occurred, including damage to 218 hospitals and clinics, 181 assaults on other health facilities (such as pharmacies, blood centres, dental clinics, and research institutions), 65 attacks on ambulances, and 86 attacks on medical personnel that resulted in 62 deaths, according to the report. Severodonetsk City Multiprofile Hospital in Luhansk was hit 10 times between March and May 2022.

“To attack the most vulnerable – babies, children, pregnant women, and those already suffering from illness and disease, and health workers risking their own lives to save lives – is an act of unconscionable cruelty,” United Nations Population Fund Executive Director Dr Natalia Kanem, UNICEF’s Ms Russell, and WHO’s Dr Ghebreyesus said in a joint statement on 13 March 2022.

Up to December 2023, there were over 1,200 documented attacks on health workers, patients, hospitals, clinics, and ambulances, across 19 countries, resulting in nearly 700 deaths, the WHO’s Director-General told reporters on 15 December.

The South Sudan conflict killed 33 UN staff and another 33 were killed in Afghanistan in 2009, as US troops battled the Taliban, according to the Aid Worker Security Database. The database is a US-funded platform that produces reports on significant security incidents affecting aid workers.

From March 2011 through June 2022, Physicians for Human Rights verified more than 600 attacks on 400 health facilities in Syria and the killing of at least 945 medical staff.

While there are laws aimed at protecting doctors and other humanitarian workers in wars, such as those in Gaza and Ukraine, the evidence from experts and humanitarian groups shows that such laws, like those protecting women and children, are frequently flouted or simply ignored.

International Humanitarian Law (IHL) forbids intentional attacks on civilians. The core of modern International Humanitarian Law is set out in the four Geneva Conventions of 1949 and their additional protocols. Every state in the world has adhered to the Geneva Conventions, according to the Irish Department of Foreign Affairs.

“Although not all states are yet party to the two additional protocols of 1977, many of the rules set out in these instruments enjoy the status of customary international law applicable to all states,” according to the Department.

The IHL stipulates that targeting critical civilian infrastructure, such as hospitals, could constitute a war crime. It also prohibits attacks on military objectives that do not take adequate precautions to avoid harm to civilians. “Respect for IHL saves lives, reduces human suffering, and ensures protection of human dignity,” the Irish Red Cross states on its website.

In this context, an initial ruling by the International Criminal Court on 26 January in a genocide case filed by South Africa against Israel to prevent acts of genocide against Palestinians, was welcomed by humanitarian organisations and many world leaders. The substantive case will take a number of years before a final judgment is reached. The UN Secretary-General said he hoped that Israel would comply with the court order.

“Bringing about an end to this conflict and to the death and destruction in Gaza is a priority that must be pursued on all fronts – political, diplomatic, humanitarian, and legal,” Tánaiste Martin said in welcoming the ruling. “We must ensure that all parties to this conflict are held to account for their actions.”