Introduction

Gaza, which has been under heavy blockade and occupation for 17 years and is a small piece of land with the world's most densely population, is defined as an 'open air prison' almost all over the world. Unfortunately, occupation and blockade are not only issue of the 2.3 million Gazans who are trying to hold on to life under the harsh conditions created by this blockade; Gaza is systematically and continuously attacked by Israel, all infrastructure systems are destroyed, and tens of thousands of people are killed, injured and disabled. Following the Oslo agreement signed in 1993, Israel's withdrawal from Gaza took more than 12 years and was completed in 2005. Thus, the oppression in Gaza, which continued with constant and daily murders, arrests and harassment before 2005, turned into systematic and destructive attacks that Israeli administrators called 'lawn mowing' since 2006, and long-term and devastating attacks took place in 2008, 2012, 2014, 2021, 2023-2024. These attacks generally targeted children, women and Gaza's vital infrastructure, especially the healthcare system.  When compared to İsrael’s previous attacks, the attacks in 2023-2024, targeted all basic vital infrastructures of Gaza such as shelter, health, education and cultural heritage of Gaza and these were largely destroyed.

Table 1-Financial burden of the attacks by years

In this table, when compared to previous attacks, the entire infrastructure of Gaza was largely destroyed in the 2023-2024 attack.

Graphic 1- Percentage of damage caused by last attack (cross-sector)

When all sectors are evaluated in the 2023-2024 attacks, it can be seen in graphic 1 that the most damaged sector was healthcare infrastructure, with a rate of 85%.

How these devastating attacks on basic vital infrastructures are legitimized or rationalized in the military literature is not my area of expertise as a physician, but it can be said that such large-scale destructions on vital infrastructures are rare in history. I have provided emergency health support and humanitarian activities in many crisis and war zones, but I have to say that this kind of catastrophic destruction is truly rare. In natural disasters such as earthquakes and floods, human beings can find the motivation necessary to rebuild life, and they usually have. However, the difference between this catastrophic destruction and disaster is that it is almost entirely human-caused and destroys the hope and motivation for re-building life in human beings, creating intense uncertainty about the future and a sense of abandonment. For this reason, destruction in Gaza compared to the destruction during the occupation of Iraq, the war in Afghanistan, internal conflicts in Yemen, Somalia and similar places is catastrophic and even though the figures and financial value, loss of life and similar numerical data may be relatively different, but the scale of the destruction in Gaza is unprecedented.

Experts from different disciplines will work on various aspects of this catastrophic destruction for a long time. It is obvious that this unprecedented, human-induced destruction in world history will have long-term consequences not only in Gaza but throughout the world. This short report provides summary information about the effects of this catastrophic destruction in Gaza on the health sector.

Healthcare Infrastructure

The Palestinian Ministry of Health was established in 1994. It has been struggling wholeheartedly for the health of the Palestinian people since its establishment. Despite adverse conditions and financial difficulties, important medical successes have been achieved, as witnessed by the whole world. Despite the negative effects of the lack of resources and medical supplies, the Palestinian Ministry of Health has implemented health policies in partnership with many regional and international health organizations to strengthen the health system and improve the delivery of health services in 14 public hospitals and 49 primary health centers. In Gaza, where a total of 2.3 million people live and which has the densest human population per kilometer in the world, doctors have actually been able to produce health care close to modern standards with superhuman efforts.

Figure 1- Health Institutions in Gaza Strip (2018)

The Gaza Strip is divided into 5 administrative regions. From north to south; Northern Gaza, Gaza City, Deir Al-Balah, Khan Younis and Rafah. According to 2018 data, there are a total of 28 hospitals affiliated with the state or aid organizations in the Gaza Strip. The Ministry of Health is responsible for 14 public hospitals with a total bed capacity of 2.300.   There are 14 other hospitals with a capacity of approximately 600 beds, run entirely by voluntary organizations. There are two universities with medical faculties and three training and research hospitals in Gaza. These are Gaza Islamic University, Al-Ahzar University, Shifa Hospital, Al-Nasser Hospital and European Hospital. Universities and training hospitals in Gaza, where I have been on various dates for medical education, international scientific congresses and therapeutic studies, are the main institutions that train medical personnel for the Gaza and Palestine healthcare system. These educational institutions were consistently the most targeted institutions throughout the attacks.

In addition to these institutions, there are also 71 primary health centers, 49 of which are affiliated with the Palestinian Ministry of Health and 22 of which belong to UNRWA. These health facilities serve 2.3 million people. All health facilities continue their existence with external funds due to years of blockade.

According to The Gaza Strip Interim Damage Assessment, 85% of health institutions were severely damaged or completely destroyed in the attacks by April 2024. Partially functional health institutions have very limited access to electricity, water, medicine and basic medical supplies. In the photos below, the destruction in hospitals during Israel's attack on Gaza is clearly visible.

In the Israeli attacks on December 8, 2023, the Faculty of Medicine of Islamic University of Gaza was completely destroyed.

In the Israeli attacks on January 17 Al-Azhar University Medical Faculty has also been totally demolished. 

With the destruction of medical schools, medical education in Gaza came to a complete halt. With the demolition of training and research hospitals, specialization and specialist doctor training were eliminated. With the killing of rectors, deans, trained specialists and teachers of universities, training and research hospitals, a complete health massacre was committed in Gaza, and as a result, Gaza's health future was completely destroyed.

Primary Healthcare and The Patients

As a result of the attacks on the health system, basic health services cannot be provided and injured people from both natural diseases and conflict cannot be treated. The catastrophic situation created by the conflict and destruction poses significant and increasing risks to public health. Epidemic diseases develop rapidly, especially since healthy drinking water, sewerage and other city infrastructures are completely destroyed. Due to the difficulty to access food and other environmental conditions, which Israel uses as a way of punishment, malnutrition (16% of children suffer from malnutrition and it is reported to increase every day) and related infectious diseases are increasing rapidly.

Hundreds of thousands of acute respiratory infections, diarrhea, hepatitis A, scabies, chickenpox and other infectious diseases have been reported. Dozens of people, mostly children, died from malnutrition. In addition to this bleak picture, people with chronic diseases (cancer, heart failure, kidney failure, liver failure, congenital diseases) are also deprived of access to healthcare. More than 50% of people who have inadequate infrastructure for their treatment cannot be transferred due to the Israeli embargo.

Healthcare Workers

According to the reports of the Palestinian Ministry of Health and Gaza administration published in the press, 153 doctors, 124 nurses and other health professionals (dentists, paramedics, nurses, physiotherapists, dental technicians, medical students, pharmacists) were killed until mid-March 2024. That makes a total of 458 healthcare workers and all these deaths are confirmed. Senior administrators, department heads, deans and rectors of universities were murdered. In addition, many healthcare workers are missing and there is their fate is unknown. There have been reports of detained healthcare workers dying under torture. Severe physical injuries are observed in those who are detained and released. Again, in the attacks, ambulances, paramedics and ambulance drivers who transferred the injured were targeted.

A few sample cases of these massacres and arrests, which are often treated as mere numbers in the media and reports, are shared below.

Head of the Department of Surgery, Dr. Muhammad Al-Ronn who was arrested by Israeli soldiers while working at Gaza Indonesia Hospital was released after being held captive for 50 days. One of Gaza's best surgeons, Dr. Muhammad refused to leave Gaza and his patients.

During the first occupation of Shifa Hospital, hospital director Dr. Mohammed Abu Salmia was detained. At the beginning of March, Israel completely destroyed the hospital. 200 people were killed and 900 people were detained. The fate of the detained healthcare professionals is not yet clear. Although several months have passed since his detention, there has been no news from Dr. Mohammed Abu Salmia.

Intern Dr. Khaleel Skaik, one of the students of Islamic University of Gaza Faculty of Medicine was working as a volunteer at Shifa Hospital and he was arrested after the hospital was occupied by Israeli forces. Khaleel, who was later released, was exposed to an armed attack and injured while returning home. Returning to the hospital after his treatment, Khaleel continued his duty for a while, but was arrested again during the evacuation operation carried out by the Israeli occupation army. He was released on May 2, 2024.

Gaza University Faculty of Dentistry Dean Prof. Dr. Jamal Naim's mother, his 3 daughters: Dentist Sema Naim and Dentist Şeyma Naim, 15-year-old Betül, her grandchildren Lea (3), Rema (1), Lara (9 months) and Taisser (3) were murdered during Israeli attacks. And he was injured because of the attacks.

Shifa Hospital Orthopedics and Traumatology Department Head Dr. Adnan Al-Brush was arrested in December 2023, and it was reported that he was killed in April 2024 because of torture.

Former Dean of Islamic University of Gaza Faculty of Medicine, Prof. Dr. Omar Ferwana, his daughter family physician Dr. Aya Ferwana, along with his wife, children and grandchildren, were murdered because of the Israeli attack on his house in Tel el-Hawa, Gaza, on October 15, 2023.

Islamic University of Gaza Faculty of Medicine Rector Prof. Dr. Sufyan Tayeh was targeted and killed in Israeli attacks.

International Law

Article 8/e of Additional Protocol No. I to the Geneva Convention dated 1949 strictly prohibits attacks on healthcare workers and infrastructure in cases of war and conflict. Both the Geneva Convention and the rules of the international law of armed conflict clearly state that healthcare facilities and personnel in the conflict zone must be protected.

According to International Human Law, hospitals, health institutions and organizations cannot be attacked. This protection covers the injured and patients, as well as medical personnel and healthcare transportation vehicles. In non-international armed conflicts, this prohibition is included in Common Article 3 of the Geneva Convention, which allows the transfer and treatment of the wounded and sick. The Security Council accepts this article as a rule of international law.

The sick and injured should be respected (not attacked, killed or mistreated), protected, searched if missing, and transported to the place of treatment without any discrimination other than medical reasons. Exposure of medical personnel to attacks impedes the protection provided to injured and sick people.

Under international human law, everyone has the right to access the highest attainable standards of physical and mental health. Attacking patients, injured people, medical institutions and organizations, destroying infrastructure, and preventing access to basic food, shelter and medicine are also the denial of this right, thus prohibited.

Israel, as the occupying power, not only does not fulfill its duties and responsibilities under international law towards the population living in Gaza, but also commits serious crimes by systematically massacring the civilian population, carrying out heavy and destructive attacks on vital infrastructure, and preventing access to the most vital needs such as food and water.  Unfortunately, it does not seem possible for now for these crimes, which are being committed with the support of the great powers of the world, to be tried and convicted by international institutions. Although this trial and deterrent punishment seems not in sight for now, scientists and relevant institutions should record Israel's attacks and activities, which are serious crimes in terms of the most basic humanitarian and universal law.

World public opinion is in great anger due to the inhumane crimes committed by Israel. People all over the world organize protests almost every day, and human rights, universal law, global institutions and values ​​are eroded and become meaningless every day. On the other hand, it is truly thought-provoking that major medical organizations/societies in the West, of which physicians around the world are members, do not condemn Israel's attacks on healthcare professionals and the healthcare system in Gaza or do not take any initiative to establish a ceasefire. This situation damages the faith in these professional organizations, as well as other international institutions. It is exemplary that these institutions, which are at the forefront of advocating victims of crimes committed and crises caused by other states and organizations, display such a passive image when it comes to Israel. Physicians constitute the most educated group of people in society, considering their long education process. Moreover, the main duty of physicians is to protect people's health and restore those whose health is impaired. Despite this, their silence is incomprehensible. Despite this passive stance of global professional organizations, it is seen that volunteer doctor organizations and our colleagues from almost all over the world are doing important work in Gaza, both individually and institutionally.

The ongoing ominous and systematical attacks of Israel to sick people, hospitals and whole health infrastructure in Gaza shows that the voluminous international law codes are even less important and dysfunctional than draft papers when it comes to Gaza. The blood of children, women and innocent civilians who have been brutally murdered for months has spilled into the hands of those who remained silent about this massacre and did not take action, especially Western states and global institutions. While it should be a shock when an innocent person, man, woman, especially an infant or child is brutally murdered, on the contrary, carrying wood to this fire of brutality, providing support, and preventing access to the most basic human rights of life, nutrition and health are inhumane and it doesn’t correspond to any lowest level of inhumanity.

Conclusion

It is an admirable and unprecedented sacrifice that Gaza healthcare workers, doctors and support staff, who are the biggest target of Israeli attacks, have not left the hospitals since the first day, despite all the destruction, attacks and obstructions, and have worked to create opportunities under impossible conditions, in many cases even giving up their families, for the health of people. And it is an honorable act.

Apart from other vital sectors health infrastructure, which is the basic vital infrastructure, especially in times of war and conflict is also emotional and physical shelter for people affected from these conflicts. In addition to operating rooms, laboratories, outpatient clinics and services, which are the basic units of treatment, hospital corridors and gardens are places where people take shelter emotionally and physically in almost every war and conflict. It is clear that the intention of this catastrophic destruction of the healthcare system in Gaza is to destroy the hopes of life and future of the people of Gaza and Palestine. Documentation of these serious crimes and attacks, in clear violation of international law, is of vital importance for future trials.

Despite all this oppression, the honorable people of Gaza have not been defeated and will not be defeated. Gaza has become the conscience of humanity. It gave new life to all human and moral values ​​that were melting and shrinking. While the cruel world thrives on cruelty, Gaza, with its stance in every field, teaches humanity again about self-restraint, truth, conscience and high human values. It seems that the world cannot heal until Dear Gaza heals.

The repair of this heavy situation will take years, both in terms of cost, time and the heavy human/conscientious burden it creates. With its effects, the destruction in Gaza has gained a global character and has dragged all humanity into darkness. I hope that these crimes, which cause deep wounds in the conscience of every person, will end as soon as possible.

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