Indian Journal of Medical Ethics


War on healthcare services in Gaza

Thalia Arawi

Published online first on January 17, 2024. DOI:10.20529/IJME.2024.004


This article looks at the October 2023 war on Gaza in the context of the effects of wars on healthcare systems. I will begin with a brief historical overview of the so-called Israeli-Palestinian conflict to clarify the special status of the Gaza Strip and the hostilities since October 7, 2023. This will be followed by a description of the major distinguishing characteristic of this war, namely, the systematic assault on the healthcare system. Finally, I will attempt to explain the conduct of this war using a necropolitical lens.

Keywords: war, ethics, necropolitics, human rights, Gaza

“The idea that some lives matter less is the root of all that is wrong with the world.”

                                                                                                                   — Paul Farmer [1]


“We have been trying to perform excruciatingly painful procedures, with no ketamine or even Tramadol. With nothing …”

“The situation now is to die silently. Only death is all over around, no response, no help. Everything stays till.”

These statements read like part of a Frankensteinian nightmare describing a failing healthcare system; but these are actual testimonies of surgeons treating the wounded in the Palestinian Gaza Strip ever since October 7, 2023, with over 22,438 residents having been killed as on January 4, 2024 [2]. The first assertion comes from an X post by a surgeon from Médecins Sans Frontières (MSF) [3] at Al Ahli Hospital and the second from a Gazan plastic and reconstructive surgeon [4] in Al Naser Hospital on his personal Facebook account, after amputating the arm and the leg of a child who eventually succumbed to her wounds. What makes such violence horrific is that in spite of the understanding that, “even in destruction, there is an order and there are limits”[5], in Gaza those limits have been breached by the Israeli invasion almost daily, with no sign of ceasing.

One’s first impression on reading the narratives above is that of a breakdown of the healthcare system. Yet, it is not a breakdown, but a total and deliberate decimation, in defiance of international humanitarian law (IHL) which forbids the targeting of medical facilities. Most of the 36 Gaza hospitals have been made either completely nonfunctional or are trying to function with a lack of almost everything needed to treat patients, and with a 190% occupancy [6].

Visiting Gaza, the International Committee of the Red Cross president, Spoljaric, stated that “[t]he level of human suffering is intolerable. It is unacceptable that civilians have no safe place to go in Gaza, and with a military siege in place there is also no adequate humanitarian response currently possible” [7]. Dr. Richard Peeperkorn, WHO representative in the occupied Palestine territories, simply noted that Gaza’s “health system has been crippled by the ongoing hostilities…”.[8]

This article raises the perennial Machiavellian question of whether the ends justify the means. Is it acceptable for political leaders to breach the profoundest moral restrictions to reach what they see as the greater good for their own populations? To clarify this, it is necessary to briefly outline the historical background to this conflict.

A brief historical background

The so-called Israeli-Palestinian issue can be traced back to World War I, with Britain promising to establish a state for the Jewish people in Palestine under the infamous Balfour Declaration. November 2, 1917 [9], marked the day when the normal lives of Palestinians were disrupted as their homes, lands, and life began to be taken away by the Jewish migration to Palestine which continued during World War II with many escaping the Nazi regime in Europe and its horrific targeting of people on religious grounds. 1947 marked the arrival of a ship transporting Jewish refugees from Europe to Palestine which was then under British rule. Photographs show the ship full of Jewish refugees trying to enter Haifa port in Palestine holding a sign stating: “The Germans destroyed our families and homes — Don’t you destroy our hopes.” While Zionist organisations persisted in campaigning for a homeland for Jews in Palestine, under the false claim of “giving a land without people to a people without a land”[10], another expression of the colonial “Terra Nullius” concept legitimising the obliteration of the native inhabitants and formulating the “legal” and “moral” ground for sequestering native lands applying the logic of elimination, in the words of Theodore Herzl, the founder of Zionism, who said: “If I wish to substitute a new building for an old one, I must demolish before I construct.”[11]. With settler colonialism’s insatiable thirst for more land, the uprooting continues even today with the appropriation of thousands of acres of Palestinian land [12].

The horrors of the Holocaust, coupled with postwar antisemitism and violence, fueled the Zionist multi-faceted propaganda claiming Palestine as the “promised land” for Jews, prompting a Jewish exodus to Palestine. The taking over of Palestine was, according to the British Zionist leader Chaim Weizmann, to be done as noted in the British proverb of the camel and the tent [13]. On May 14, 1948, the founding of the State of Israel was proclaimed and celebrated by Israelis as their Independence Day, yet remembered by Palestinians all over the world as the day of the Nakba (“the Catastrophe”) and 75 years later, Palestinians are still pushed from one oppression to another, with the majority residing in the West Bank, Gaza and some Arab countries. The Gaza Strip has been under sea, air and land blockade since 2007, and has come to be known as the biggest open-air prison in the world.

By promising and giving away land that it did not own, Britain breached the most basic human rights, marking the beginning of one of the worst cases of aggression in the world, namely, the Israeli military occupation of Palestine, robbing the owners of all their human rights, and prompting several acts of resistance by the Palestinian people, ironically referred to as “the Arab-Israeli Conflict”. The Palestinians achieved some “victories” since 1987, which resulted in declarations condemning Israel for violations of the human rights of protestors [12].

How is the current invasion of Gaza different?

On October 7, 2023, Hamas militants launched the fiercest attack on Israel in decades, taking the state of Israel by surprise. The Middle East Monitor reports that this operation “launched by Al-Qassam Brigades on October 7, dealt an unprecedented, historic blow to Israel since its founding 75 years ago. It was a stunning strategic military and security attack, storming a significant area of the 1948 occupied territories and inflicting the highest toll of killed, wounded and captured Israelis compared to all the battles the Palestinians have fought since Israel’s establishment, and even most Arab-Israeli wars.”[14] With the rise of social media, that attack and the subsequent mass atrocities committed by the Israeli Defense Forces were visible for all to see and perhaps for the first time in the world’s history, most countries and populations (with the exception of most of their governments) began accusing the state of Israel of genocide and ethnic cleansing, and to call for a Free Palestine.

The war on healthcare

The World Health Organization (WHO) launched its 2015-2030 agenda for Sustainable Development Goals (SDGs) [15]. aiming to reach universal health coverage by monitoring systems of health inequalities between countries or at the state level (SDG3). However, the health systems in several war-torn countries such as Yemen, Iraq, Syria, Ukraine, South Sudan, Palestine, etc continue to weaken and have been struggling with limited medical and non-medical resources, shortages of trained medical staff and of fully functioning health facilities [16]. A quick look at the history of wars reveals their drastic impact on healthcare infrastructure and superstructure and how humanitarian crises rapidly escalate the health needs of populations, especially among the most vulnerable groups. International medical and humanitarian responses to these needs are often insufficient in countries suffering from a deterioration in institutional healthcare. Humanitarian crises lead to complex situations requiring varied evidence-based interventions, which again, are rendered impossible by war and political conflict.

Both the Geneva Convention and IHL Rule 25 explicitly state [17] that “military and civilian medical personnel exclusively assigned to medical duties must be respected and protected in all circumstances” which makes any deliberate attacks against care workers or targeting of health facilities a war crime and a clear breach of IHL laws. The October aggression on Gaza has revealed an “unrelenting war” on the healthcare sector [18], amounting to a war within a war. The long-term effect of such targeting will take several years to reverse, leaving a long interval for more disease to spread and fresh healthcare problems to arise. In addition, the specific targeting of healthcare facilities and personnel engenders serious doubts about the safety of any future healthcare structures which can at any time be targeted in the absence of international deterrence. While the aggression on Gaza is not new, the 2023 violence is marked by a new form of war: a war on healthcare overtly supported by an infamous letter from 45 influential Israeli rabbis calling on Netanyahu to bomb hospitals [19] and an unprecedented breach of medical ethics with it being endorsed by 400 doctors (including family physicians and paediatricians) [20]. At least 364 attacks on healthcare services have been documented in the occupied territories since October 7, with reports to the effect that the Indonesian hospital in Gaza was bombed 35 times [18]. Numerous healthcare workers have been wounded, detained, or incarcerated, including the general director of Al-Shifa Hospital who was arrested on November 23, and his whereabouts remain unknown to this day. Dr Mofokeng, United Nations (UN) Special Rapporteur on the right to health, declared that “the health infrastructure in the Gaza Strip has been completely destroyed and that “we are in the darkest time for the right to health in our lifetimes.”[18] Sadly, neither laws, nor regulations, nor UN resolutions were able to halt this annihilation of the healthcare system.

With the intentional dismantling of healthcare, the targeting of water, sewage, and essential food, the impact of this self-perpetrating disaster will continue long after this phase of the aggression is over. People no longer have a place to be treated, or clean water to drink, and suffer from malnutrition and its sequelae, all of which provide a breeding ground for communicable diseases, respiratory illnesses and diarrhoea, epidemics, non-communicable diseases, and even cancer — with the only cancer hospital in Gaza targeted twice in October [21]. The WHO has already reported “an astounding increase in cases of diarrhoea, particularly amid infants and children, and noted “very serious signals around acute jaundice syndrome” in the Palestinian enclave [22].

With the public outrage caused by Israeli Heritage Minister Amichai Eliyahu’s declaration of support for the nuclear bombing of the Gaza Strip, reports emerged of Tel Aviv using internationally forbidden weapons including phosphorus, fissile, vacuum, and depleted uranium, missiles that leave nothing but bones on the body, some of which completely dissolve the body, and the resultant spreading of toxins [23]. The nature of weapons used was revealed by the nature of wounds, which included incendiary burns that cover most of the body, and weapons that would fragment into a number of guillotine-like disks causing amputations in the body. We still do not know the future effects of these weapons and the diseases to which they might lead.

In addition to the war’s direct wounds on the human body, malnutrition, starvation, the loss of homes and important family medical records continue to grow, and their effects will be felt for decades to come. The ruthless aggression is leading to a tsunami of mental health problems not easy to address, including but not limited to the effects of displacement, witnessing fellow humans shredded or losing limbs; and not being able to grieve over the continuing losses of dear ones, post traumatic stress disorders (PTSD) and depression will become even more manifest after the immediate violence is over and will continue for a good number of years. Gazans have already a high record of PTSD from previous aggressions which were generally less intense than the 2023 one which has spared no one. According to Save the Children, a charity organisation for children, “children are experiencing a whole host of signs and symptoms of trauma including anxiety, fear, worry about their safety and that of their loved ones, nightmares and disturbing memories, insomnia, bottling up emotions and withdrawing from loved ones”[24]. These illnesses also take a toll on healthcare workers who suffer traumatic flashbacks and mental health issues. Precisely because of the healthcare catastrophe caused by violence and the siege, the Executive Board of the WHO announced an emergency session on December 10 to discuss the health crisis in Gaza and the West Bank, while the Palestinian ambassador to the United Nations in Geneva, Ibrahim Khreisheh, is seeking to increase medical aid and the entry of foreign healthcare workers to the Strip.

Notwithstanding the danger, healthcare workers did not stop providing services to patients until the total breaking of the healthcare system and exhaustion of resources exacerbated by the siege. This led to surgeons having to resort to basic washing liquid and vinegar to clean wounds to keep the scarce saline solution for more serious needs and to perform surgeries and amputations without anaesthesia. The social media was filled with the story [25] of a Gaza surgeon weeping in devastation after losing his own son during an amputation he had to perform on him without anaesthesia. Doctors reported having no morphine or ketamine; patients showing signs of worsening infection ultimately led doctors to perform painful attempts at cleaning wounds and amputating limbs that could otherwise have been treated [26]. British Palestinian doctor, Abu-Sittah reported the tragedy where triage was done with the help of family members based on factors such as how many siblings (or not) the patient had and remarked on the large numbers of people in the operating theatre suffering from fragmentation missile wounds inconsistent with other etiologies and requiring what he called “‘guillotine amputations’ in ‘very tough’ parts of their bodies — such as the mid thigh, where medics had to saw through a web of thick muscles, and the femur, the strongest bone in the body.”[26] Fragmentation explosives are exceptionally lethal, bursting into a huge number of small and fast-moving lethal metal fragments upon collision.

Finally, I examine the ferocity of the invasion of Gaza from a philosophical and necropolitical perspective.

Überstates: Undercutting healthcare as a strategy of war

October 7 marked a Nietzschean moment in history in that shared values related to human rights and expressed in regulations such as the Declaration of Human Rights, the IHL, and the Geneva Conventions, are not only devalued, but unreservedly rejected. They are considered slave moralities hostile to life, espoused by the “weak” and thus need to be replaced by those that are based on the will to power. The ones with the power to shape the world have diametrically opposed values regarding life. Nietzsche said: “Man himself becomes the determiner of values; he does not require to be approved of; he passes the judgment: What is injurious to me is injurious in itself; he knows that it is only himself who confers honor on things; he is a creator of values.”[27] Modern day überstates (to coin a new term) are based on colonial settler ideologies that perpetuate the logic of abandonment within a necropolitical construct based on Foucault’s biopolitics. These überstates operate by othering the “subject” under their control, propagating epistemic violence which rejects all other kinds of knowing but their own, and trivialising indigenous knowledge. Gazans (and Palestinians in general) are regarded by the State of Israel as individuals who have nothing to give — whose experiences and narratives are rejected and silenced — and have been devalued and dehumanised via epistemic violence for more than 75 years now. This silence, however, has been shattered by a new form of resistance via social media which, for the first time, makes the Palestinian narrative and suffering visible to everyone as it actually is, a narrative of people with a land that is being brutally taken away from them as aptly expressed by Paul Farmer thus: “human rights violations are not accidents; they are not random in distribution or effect. Rights violations are, rather, symptoms of deeper pathologies of power and are linked intimately to the social conditions that so often determine who will suffer abuse and who will be shielded from harm.” [28]

Necropolitics and healthcare

The attack on healthcare in Gaza is a manifestation of what Foucault called biopolitics, “The set of mechanisms through which the basic biological features of the human species became the object of a political strategy, of a general strategy of power… It is the power to ‘make’ live and ‘let’ die. The right of sovereignty was the right to take life or let live. And then this new right is established: the right to make live and to let die.” [29] The attack on healthcare facilities and infrastructures in the Gaza Strip marks a shift from biopower to necropower, from aiming at the individual to targeting whole areas and communities. Gaza is the necropolitical paradigm of the concentration camp as visualized by Giorgio Agamben, “a space that is opened when the state of exception begins to become the rule” [30], where Gazans are reduced to the status of homo sacers (individuals that can be killed with impunity, for they are forbidden from living in a politico-legal civil society) and are reduced to no more than a biological existence fighting for mere survival, with the West Bank camps seen as “an experimental laboratory for control and surveillance” where the occupier rules through “the normalization of a state of exception”[31]. Not only do such targeted civilian populations lack access to healthcare facilities; but healthcare workers, hospitals and ambulances have been specifically targeted. Dr Hammam Aloh, a nephrologist working in Al Shifa Hospital who refused to flee believing in his duty as doctor to help the injured was one such “casualty”, who said in his last interview: “If I leave, who will treat my patients? We are not animals. We have a right to receive healthcare”[32]. This is not to argue that animals do not have the right to be treated (which is another issue altogether) but refers to the numerous times Palestinians have been referred to as an inferior race by Israeli government officials such as the Israeli Defense Minister Yoav Gallant [33]. There are many like Dr Hammam in Gaza who should be hailed for their superb humanism and bravery; but are killed instead of receiving the Nobel Peace Prize. That is but another manifestation of an Übermenshian state that controls the lives of an entire people by denying them healthcare, and thus challenges global definitions of values and rights. Gaza has become “the culmination of spatial exclusionary arrangements that existed in an incipient state during the early phases of modern settler or genocidal colonialism”[34]. According to Jewish philosopher Judith Butler, who has often written on the precariousness of life and how different lives are valued differently, the genocide happening in Gaza is “a systematic undercutting of the livelihood, the health, the wellbeing and the capacity to persist” [35]. Seen through a Butlerian lens, Palestinians are being denied a basic humanity which reduces them to otherness so that , in case of death or loss, they are not seen as worthy of grief. Consequently, we mourn for some lives but respond with coldness to the loss of others [36]. Butler, also known for her theory of “grievability”, argues that every life is precious and as such, we are charged with maintaining life to the best of our ability and that decisions to provide healthcare or to terminate a life in war are socially constructed practices [36]. She continues, saying that Palestinians are treated as not being grievable, that their lives and deaths do not matter because “they are not just less than human (..) but a threat to what the idea of a human is, that is being defended by Zionist politics, shared by Israel and the U.S. and many Western powers.” [35].

11-year-old Anas requested water to quench his thirst after his last surgery, then gasped his last breath. The surgeon treating him said: “I got him some water and helped him drink. That will be my lasting memory of him. The boy was thirsty in his last moments” [37]. This last tribute to Anas and to the many Anases in Gaza was a retweet reaching 540.6K This testifies to how precious life is to most people, regardless of how much states may try to devalue it.

Albert Camus’s words in his Nobel Prize Acceptance speech reverberate in this humanitarian crisis: “Each generation doubtlessly feels called upon to reform the world. Mine knows that it will not reform it, but its task is perhaps even greater. It consists in preventing the world from destroying itself.” [38] We have this great task ahead of us, and if we fail, we fail humanity at large.


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