International humanitarian law prohibits attacks on hospitals and health care facilities, or against patients, doctors, and their means of transport, during a conflict. A health care facility can lose its protected status if it is used to “commit acts that are harmful to the enemy,” according to the International Committee of the Red Cross (ICRC).

“Hospitals have special protection status underneath the Geneva Conventions and the Law of Armed Conflict,” says Nathaniel Raymond, a human rights investigator and a coauthor of the study. “To intentionally strike a hospital, the protocol required is the most restrictive for any type of civilian infrastructure. An armed party to a conflict must ensure that the hospital is notified that it has lost protected status, and efforts are made to ensure the evacuation of those facilities prior to any kinetic strike. That is what the law requires.”

In a lengthy response to WIRED’s questions about what measures it has taken to prevent damage to health care facilities, the IDF defended its military operations. “A central feature of Hamas’ strategy is the exploitation of civilian structures for terror purposes,” says an IDF spokesperson. “It is against this context of widespread exploitation of medical facilities and intelligence indicating their knowledge and even participation in terror activities that Israel has apprehended and questioned individuals in Gaza, including medical staff. We reiterate that individuals found not to have been involved in terrorist activity are released after questioning.”

The IDF has alleged that Hamas was operating out of tunnels underneath Al-Shifa, the largest hospital in Gaza, thereby making it a legitimate target. IDF forces raided the hospital on November 15. The tunnels have not been proven to have had a military function, and the legality of that IDF military operation remains in dispute.

Even in cases where the military has leveraged civilian structures, combatants are expected to exercise what IHL dubs “proportionality” and “precaution,” meaning that any attack should be done such that civilian harms do not outweigh the military benefit. “This does not mean there’s free license to attack,” ICRC chief legal officer Cordula Droege said in an ICRC video posted November 2 on X. “The party to the conflict has to do everything feasible in order to avoid or at least minimize harm to patients and medical staff.”

Although the destruction of health care facilities in Gaza is far more extensive, the WHO also recorded “33 attacks on health care in Israel during the violent events of October 7.” The WHO cautioned Hamas and Israel to remember “their obligation under international humanitarian law to respect the sanctity of, and actively protect, health facilities.” An independent UN Human Rights Council commission also says it is “collecting and preserving evidence of war crimes committed by all sides since 7 October 2023.”

The implications for Gaza’s health system have been disastrous. Even in the earliest weeks of the conflict, doctors warned that hospitals were running out of space to treat the wounded and were operating without access to anesthetics or even clean water. Hospitals and the health care system have also seen continued destruction. On January 3, the WHO estimated that only 13 of the 36 hospitals in Gaza remained operational. The WHO also says that instances of disease in Gaza have skyrocketed as access to health care, food, and clean water has plummeted.

Poole says she hopes the research leads to further investigations to “ascertain whether or not the medical complexes were getting distinction, proportionality, and precaution principles that protects them through IHL” throughout the course of the conflict.

“If the principle of distinction was being respected in this conflict, there would be a stark difference in our findings between special protected infrastructure—in this case, health facilities—and non-health facility infrastructure,” Raymond says. “What we find instead is that there is no difference.”

Update: 2/12/2024, 8:40 am ET to clarify the description of the satellite material on which the researchers based their analysis.


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