Safeguarding healthcare workers in Gaza and throughout occupied Palestine

SUMMARY BOX.

• International humanitarian law stipulates specific obligations during armed conflict, including the protection of healthcare and humanitarian workers.

• There has been a recent increase in attacks on humanitarian workers in places affected by armed conflict.

• Israel’s egregious violations of international humanitarian law in Gaza and the West Bank are among the leading drivers of this disturbing trend.

• The absence of respect for existing safeguards for humanitarian and healthcare workers and other protected persons in Gaza is an integral aspect of the intentional disintegration of the Palestinian healthcare system.

• More research is needed to better understand how systematic attacks on healthcare workers, alongside a lack of accountability for such attacks, impacts healthcare systems and people living in proximity to situations of extreme violence.

• Most urgently, legal and medical institutions must advocate clearly and take concrete action to stop genocide and to safeguard healthcare and human rights, including the right to self-determination, in Gaza and other places affected by political and military violence.

In grave contravention of international humanitarian law (IHL), Israel has systematically attacked healthcare workers (HCWs) and health infrastructure throughout Gaza.¹,⁵ Indeed, ‘the number of aid workers killed in Gaza in the past year is the highest ever in a single crisis’.⁶ As early as January 2024, the International Court of Justice (ICJ) determined that Israel’s simultaneous denial of water, food, medicine—including medical care more broadly—shelter, fuel and electricity, compounded by unprecedented attacks on civilians and civilian infrastructure, plausibly constituted genocide.⁷ A growing body of evidence of both intent and effect now lends even greater weight to accusations that Israel is committing genocide against the Palestinian people.⁸,¹¹ Despite provisional measures ordered by the ICJ to avoid killing civilians, and to allow immediate and effective humanitarian assistance into besieged Gaza, the situation in Gaza has continued to deteriorate precipitously.

Tangible safeguards are non-existent for Palestinians, including HCWs and humanitarian workers, throughout occupied Palestine. Following the reclassification of missing people during the first phase of the ceasefire, at least 61,700 Palestinians are reported to have been killed in Gaza since October 2023, while most of the pre-existing infrastructure required to save and sustain life has been damaged or destroyed.¹² Even after the violence subsides, thousands, and perhaps even hundreds of thousands, of sick and injured Palestinians are predicted to die due to the absence of basic services.^{13 14} Many more people will be left with debilitating physical, psychological, and long-term rehabilitative needs.

HCWs and humanitarian workers who administer medical care and provide other forms of essential support in conflict and other crisis-affected contexts always face considerable risks. Yet, Israel’s repertoire of protracted occupation and direct military violence in Gaza have produced a precarious environment for HCWs, which is unprecedented in recent history.^{15 16} As of 4 December 2024, the WHO documented at least 591 healthcare attacks in Gaza in which at least 854 people were killed, while an additional 659 attacks in the West Bank killed at least 25 people and left many more seriously injured.¹⁷ Healthcare Workers Watch Palestine has meticulously collected information on health workers killed and detained in Gaza since October 2023. As of 20 September 2024, at least 595 HCWs had been killed, constituting over 2.5% of Gaza’s healthcare workforce.¹⁸ In the same month, a report published by the Ministry of Health in Gaza reported that 1151 Palestinians working in Gaza’s health sector had been killed, of whom 986 had been verified.¹⁹ In addition, over 300 Palestinian HCWs have been detained, with many tortured and some killed in Israeli prisons.^{1 20 21} Notably, Israel’s attacks on the Palestinian healthcare system and its workers are not new and long predated the escalation of violence since October 2023.¹⁵

The deliberate denial of access to water, food, medicine and medical care more broadly, shelter, fuel and electricity has had a profoundly harmful impact on all Palestinians.¹⁶ Most recently, Israel’s protracted siege and subsequent destruction of Kamal Adwan Hospital in northern Gaza, including the arbitrary detention and enforced disappearance of both patients and staff, including its medical director Dr Hussam Abu Safiya, is a particularly egregious example of Israel’s active obstruction of the ability of HCWs to maintain essential health services in Gaza, and administer necessary care for their patients.^{22 23} Despite almost insurmountable challenges, profound personal risks, and widespread, repeated and continued displacement, Palestinian HCWs continue to work under the most horrific conditions in order to provide urgently needed healthcare to patients.²⁴

Israel has attempted to justify its systematic attacks on healthcare facilities by claiming that hospitals are being used as ‘command-and-control centres’ by armed combatants. However, to date no verifiable evidence has been produced that would justify revocation of the protected status of these facilities.^{4 25} Israel and its military arm have failed to take adequate precautions to avoid harm to civilians, patients, staff and essential health educational, social and cultural infrastructure, as is clearly stipulated under IHL.⁴ The upshot of Israel’s strategy is that there are currently no safe spaces for civilians, HCWs or other protected persons anywhere in Gaza.

Profound psychological distress and moral injury is an established reality for HCWs in Gaza and throughout occupied Palestine. This extends to communities of all faiths and backgrounds who bear witness to repeated acts of violence and dehumanisation that violate our commitment to human rights and to our medical and ethical principles.

As a global community, we must continue to reiterate the need to protect our HCW colleagues and their patients, irrespective of their background or nationality and meaningfully act to ensure that those protections are upheld. To immediately safeguard the human rights of Palestinians, and their rights under the laws of armed conflict, national and international institutions must act to end the ongoing genocide by ending all military, financial and political support for Israel for as long as the genocide, and the state of protracted occupation and apartheid, continue. Existing policies and campaigns to highlight and advocate against attacks on healthcare in any context, and in humanitarian settings specifically, must be bolstered and revisited in the context of the unique challenges faced by HCWs in Palestine. International legal institutions must act to hold the perpetrators of violence and all breaches of IHL responsible. The public, media and all state and non-state armed forces must be continuously informed about the scale and impact of this deepening global problem, and its individual and population-level consequences. Political and humanitarian systems for the protection of vulnerable people and populations must be re-examined to ensure that they are robust, especially by highlighting the ways in which they have failed to ensure adequate protection of the Palestinian people and to prevent future violations of IHL. We must meaningfully act to ensure that accountability standards and systems are fit for purpose and that necessary protections are upheld. All the above actions will require broad pressure from civil societies and professional groups to drive timely, effective change, including holding governments to account for their failure to uphold IHL. Finally, meaningful efforts are required to address personal and systemic biases that distort political action and humanitarian caregiving. Failure to uphold international legal protections and associated political commitments—most urgently in the form of action to prevent genocide—and to safeguard a minimum commitment to health and humanitarian caregiving in situations of armed conflict and genocide, will have profoundly negative consequences that extend far beyond the ongoing genocide in occupied Palestine, with widespread ramifications for people the world over.

Data availability statement

All data and references relevant to the article are included in the article.