Abstract

This article looks at the effects of armed conflict on healthcare systems in Gaza at the intersection of international humanitarian aid, settler colonialism and the ethics of war. Since October 7, 2023, there has been a systemic assault on the health services in Gaza, rooted in colonial expansion. I begin with an overview of human rights and the concept of medical neutrality. This is followed by biopolitics within Gaza and the contradictions in international law regarding the ethics of war. Explained through the lens of historical revisionism, postcolonial theory and biopolitics, I attempt to highlight how healthcare systems are increasingly becoming targets of armed conflict in Gaza as a war strategy.

Keywords: armed conflict, ethics, human rights, healthcare systems, postcolonial criticism

Introduction

“The power to narrate, or to block other narratives from forming and emerging, is very important to culture and imperialism, and constitutes one of the main connections between them.”

― Edward Said, Culture and Imperialism [1]

Since October 7, 2023, the world has seen that most of Gaza’s thirty-six hospitals and primary health centres have been bombed or besieged. Within a month of the war on the people of Gaza, the World Health Organization (WHO) verified more than 250 attacks on healthcare facilities in Gaza and the West Bank [2]. These attacks on healthcare systems in armed conflict violate fundamental tenets of international humanitarian law [3]. Not only are health centres, aid trucks, and ambulances bombed, looted and blocked, healthcare personnel and aid workers are arrested, jailed, beaten and in many cases blocked from providing care. Within this paradigm, where do the governments of the world and a unified code come into play?

Medical neutrality refers to the universally accepted principle, derived from international humanitarian law and medical ethics, which recognises noninterference with medical and health services in times of civil unrest and armed conflict. Rooted in the stance of political neutrality, it promotes the fundamental freedom of aid personnel to provide and receive care. The Geneva Conventions and their Additional Protocols serve as the basis for international humanitarian law and medical ethics during armed conflict. While they prohibit attacks on hospitals and ambulances and mandate the free passage of medical aid/ equipment, there are systemic issues in enforcement that in turn delay judgement on violation of the terms, further perpetuating violence.

If anything, the Israeli raid and subsequent attack on Al-Shifa Hospital, the single largest provider of healthcare in Gaza, which reportedly ended with many aid and healthcare workers dead, is a clear message to the member states that nothing is off limits. Al-Shifa Hospital’s destruction moved the conversation from health equity during armed conflict to the sheer annihilation of any remaining infrastructure capable of providing even the most basic first aid to the people of Gaza [4].

With jarring personal narratives that can be live streamed on your social media platform of choice, targeting healthcare systems in Gaza is far from new, and remains a method of settler colonialism used by the State of Israel. With its roots in systemic oppression, settler colonialism is a way through which a community occupies power in a region by forced displacement, land theft and an exploitation of resources [5]. A look at the history of armed conflict in the Middle East will reveal the drastic impact on healthcare superstructures and how conflict of this scale escalates the health needs of the most vulnerable groups. With Israel blocking medical and humanitarian aid from entering Gaza and simultaneously targeting healthcare systems, the health of the Palestinian people cannot be viewed in a silo outside of the occupation and the ongoing colonialism.

Narratives around armed conflict thus play an important role in the justification of what can only be defined as a Machiavellian nightmare of bombing hospitals, “till when the end can justify the means” [6]. In a post truth world, the greater narrative is written and distributed by the victors. Today, with our own eyes, we see the rise of historical revisionism, with field reporters in Gaza exposing the apathy of western newsrooms towards the mass destruction of universities, healthcare systems, and infrastructure.

Settler colonialism and healthcare: Biopolitics in Gaza

We must understand that settler colonialism is an ongoing structure, not merely a historical entity. Colonial tenets persist and continue to shape our understanding of margins in present day Gaza and the West Bank, both living examples of the same. While the global health narrative continues to divorce Palestinian health from intersections of violence and historical trauma born out of Israeli settler colonialism, we need to contextualise how targeting healthcare systems is inherently a practice of systemic oppression. During the 1948 Nakba, Israeli settler colonialism led to the expulsion of nearly 700,000 Palestinians from their homes. Today, out of the existing Palestinians, two million live in the Gaza strip and West Bank, making it one of the world’s largest refugee populations [7].

Weaponising health as a variable for control has long been an insidious practice by the Israeli State. The blockade of aid into Gaza continues to incapacitate its healthcare system. The chronic shortage of critical care medications creates a dependence on Israeli health systems which are largely inaccessible without special permits, and were, in 2022, not approved for nearly 33% of Palestinians [8]. With Israel controlling water sources, cultivable land and healthcare, there is a definite attempt to ensure Gaza and the West Bank are both spatially and socially marginalised. Between January 2018 and October 2023, the WHO documented an appalling 1382 attacks on healthcare infrastructure, services and personnel in Gaza [9]. This further reinforces the fact that systematic attacks on health systems predate October 7, 2023.

Relentless attacks on healthcare systems have repercussions in the risk of disease. The WHO reported an astounding increase in cases of diarrhoea, particularly in infants and children, and noted “very serious signals around acute jaundice syndrome in the enclave in November 2023” [10]. With over half the population of Gaza comprising children and adolescents, this creates a burden of care, which the current crippled healthcare infrastructure in Gaza cannot take on.

This rampant increase in targeting healthcare systems moves beyond human rights to uncover deeper power structures interlinked to the concept of colonial othering (determining an out-group which in all social locations is inferior and can suffer abuse). Taking from Foucault’s concept of biopolitics — where governments operate through the management and regulation of the population’s lives and bodies — we can view the attacks on Gaza’s healthcare system as a necropolitical strategy to determine who lives and who dies [6].

International humanitarian law: Contradictions and challenges

Our current understanding of medical ethics and humanitarian law is through an idealist lens where member states uphold the accountability of states in violation, in lieu of delayed enforcement from international bodies of justice. However, within the changing climate of armed conflict and an increasing tactic of targeting healthcare systems, there is a general erosion of respect for such provisions. It stems from the politicised nature of international humanitarian law, undermining its legitimacy [11]. An example of this politicised binary contradiction is Russia calling for a ceasefire in Gaza, while carrying out airstrikes in the Ukraine, while the United States of America, United Kingdom and European Union stand with the state of Israel, while calling for an end to the Russia-Ukraine war.

Additionally, some state actions such as counter terrorism laws bypass such provisions — an argument recurrently employed by the state of Israel in order to justify the ongoing attack on Gaza. Narratives play an important role in shaping our understanding of ethics. While there are internationally forbidden weapons systems and techniques, Israel has been known to use them on the people of Gaza in the guise of counter terrorism strategy. Tel Aviv was found to employ phosphorus, fissile and vacuum weapons, and missiles that leave nothing of the body but bones [12].

In addition to international humanitarian law being employed as per convenience, there is a question on the legitimacy of Palestine. While many argue that Israel’s role in the Gaza Strip and West Bank qualifies as settler colonialism and occupation, others view the current conflict with Hamas (technically a non-state actor) as a non-international armed conflict given Israel’s withdrawal of troops from Gaza in 2005. This is yet another narrative drawn to breach the core tenets of employing international humanitarian law furthering Israel’s claim to self-defence. Regardless of the semantics of legitimacy (although they hold immense power), it is understood that Israel’s campaign of counter terrorism is now recognised as having generated civilian deaths at a rate higher than any other armed conflict or war of the twenty-first century [13]. Gaza then stands as the most comprehensive lesson on the inescapable politics that underscores the legitimacy of humanitarianism when politicised by the global North.

Targeting Al-Shifa hospital: tactics of genocide

A WHO-led multi-agency mission to Al-Shifa Hospital on April 5, 2024, found that it “is now an empty shell after the latest siege”. With at least 115 beds from the Emergency Room (ER) burnt, 14 neonatal intensive care unit (NICU) incubators and the hospital’s oxygen plant destroyed, the scale of devastation has left the hospital completely non-functional [14].

In her report titled “Anatomy of a Genocide”, Francesca Albanese highlighted how genocide is defined as a specific set of acts committed with the intent to destroy a group, in whole or in part. Albanese highlights three acts of genocide committed by Israel with the requisite intent, causing serious bodily or mental harm, deliberately inflicting conditions of life calculated to bring about a community’s physical destruction in whole or in part, and imposing measures to prevent birth [15].

The targeted attacks on aid workers and destruction of the largest healthcare facility in Gaza made it clear that the intent was never counter terrorism, but the expansion of the state of Israel and the commission of the crime of genocide towards that end. Furthermore, with the International Court of Justice (ICJ) finding genocide plausible, Israel was issued six provisional measures. Challenges then also arise in monitoring violations of the ICJ ruling [16]. Today, with the advent of social media and citizen journalism, Gaza stands as the most actively documented genocide of modern history. Despite these efforts, only estimates of death and destruction exist. Thus, generating a knowledge base on violations prior to October 7, 2023, is indispensable yet precarious at best.

Health cannot be viewed in a silo outside of the social determinants that directly influence it. While popular narratives drawn around the assault on Gaza after October 7 exist, it is imperative to reflect on Edward Said’s work in Culture and Imperialism as we consume a crisis; those who hold the power to block other narratives from emerging are often the aggressors themselves [1]. Calling for a permanent ceasefire and allowing humanitarian aid to enter is now the only way for healthcare systems to rebuild their capacity and provide care to the wounded, displaced and traumatised Palestinians.