After a year of unfathomable images, videos, and testimonies from Gaza, the story of 19-year-old Shaban al-Dalou still managed to shock the world. On October 14, Israel bombed the Al-Aqsa Martyrs Hospital complex, where Shaban and his family were sheltering, and where he was receiving medical care for malnutrition and trauma after surviving Israel’s bombing of the mosque where he was praying just days before. Fire quickly spread among the tents at the complex, engulfing them in flames. Shaban’s father was able to rescue his three other children, but when he returned for Shaban, it was too late.
In a video recorded of the tent fires, the world saw Shaban’s last moments while his tent burned, his body still connected to an IV bag. Shaban’s mother was also killed in the attack. On October 18, Shaban’s 10-year old brother, whom his father had managed to pull from the tent, died from his injuries.
A few days after that, the world was riveted by the story of the Gazan paramedic who realized the covered dead body in his ambulance was that of his mother. Then came the news that the third phase of the children vaccination campaign that had been initiated due to a polio outbreak in Gaza was delayed due to Israel’s bombing and the ongoing displacement of the population.
These stories represent just a tiny portion of the countless tragedies that have occurred in Gaza since Israel began a military campaign there that multiple experts and international bodies have called a genocide. Indeed, at the end of October, South Africa submitted to the International Court of Justice its 5,000-page final collection of evidence arguing that Israel has “special intent to commit genocide.”
Israel has destroyed the ecosystem of heath in Gaza, including all of its social determinants such as access to food, water, and shelter.
Since the beginning of the war on Gaza in October, Israel has destroyed the ecosystem of heath in Gaza, including all of its social determinants such as access to food, water, and shelter. The few remaining health facilities are receiving dozens if not hundreds of patients daily with traumatic injuries, which facilities are ill-equipped to treat. Looking back over the past year allows an opportunity to trace the trajectory that has led to today’s horrendous reality.
A Year of Unending Violence and Deprivation
The scale of Israel’s assault on Gaza is unprecedented, with tens of thousands of tons of bombs being dropped on the small territory and hitting civilian infrastructure once every three hours on average. Unsurprisingly, the scale of the attack has had a cataclysmic impact on Gaza, with 38 humanitarian organizations warning in mid-October 2024 that parts of the territory were being “erased.”
By the end of October 2024, the Ministry of Health in Gaza reported approximately 43,000 fatalities and 101,000 injuries. It is well understood that this reported death toll is a significant undercount, with many dead still unreported, and many bodies still trapped under rubble. Almost all of Gaza’s population—1.9 out of 2.2 million people—are internally displaced, many multiple times and with no homes to return to. Approximately 17,000 children are orphaned in Gaza, and tens of thousands more have been injured, with the Strip becoming the site of the largest cohort of child amputees in modern history. At least 60 percent of the buildings across Gaza are damaged or destroyed, along with almost 70 percent of roads.
These figures convey a society that is under existential threat from a state operating with no guard rails and complete impunity. Yet, when looking at the sector of health, which is the most tied to life and people’s ability to resist subjugation, there are endless more indignities, violations, and tragedies.
Deprivation of Food, Water, Sanitation, and Shelter
Even before assessing Gaza’s destroyed health system, it is vital to recognize how Israel has created the conditions for rapidly deteriorating health conditions and well-being across every determinant. Just days after the October 7 Hamas attack, the Israeli government imposed a “complete siege” of the Strip, including on food, fuel, and other vital supplies. Over the past year, the amount of aid Israel has allowed to enter Gaza has been wildly inconsistent—but always hugely inadequate. At times of great international attention and pressure, such as when the initial reports of imminent famine in Gaza were released in the spring of 2024, Israel has claimed it would increase aid, and some reporting shows it did, briefly. Yet much more regular has been Israel’s effort to deny and delay aid, including by closing the Rafah border crossing with Egypt and keeping very few crossings open in its place, and by blocking multiple aid convoys that it had previously approved.
Furthermore, Israel has done nothing to secure distribution of aid once it enters Gaza, bombing multiple aid convoys attempting to transport vital supplies. Reports from early October 2024 showed Israeli forces completely blocking aid to northern Gaza. In mid-October, in response to the obviously deteriorating aid situation, the United States purportedly gave Israel an “ultimatum” to increase the amount of aid entering Gaza to at least 350 trucks daily (already an insufficient number). Yet in early November, reports showed an average of just 71 trucks entering the Strip per day.
The lack of aid has had devastating consequences for health. Gaza’s food system has essentially “collapsed,” according to the World Food Programme. The Integrated Food Security Phase Classification (IPC), the global famine watchdog, predicted that more than 90 percent of Gaza’s population will face severe food insecurity by November, with some Gazans facing “catastrophic” food insecurity. Acute malnutrition already exists across Gaza and is anticipated to skyrocket, with an estimated 60,000 cases alone expected by August 2025 in children aged six months to five years. Malnutrition weakens these children’s immune systems, making them susceptible to disease and to permanent physical and mental stunting.
Acute malnutrition is anticipated to skyrocket with an estimated 60,000 cases expected by August 2025.
Aside from the lack of food, Israel has severely limited Gazans’ access to clean water and sanitation. Gaza was suffering from severe water scarcity before October 7, 2023. Now, only one quarter that amount of water is available, reducing what is available for drinking, hygiene, and sanitation. In addition, all wastewater treatment facilities and most sewage pumps have been destroyed. This has resulted in an increase of acute diarrhea (a major cause of child mortality in Gaza for many years), skin infections, and tens of thousands of cases of hepatitis A, an inflammation of the liver that can lead to severe illness.
All these health deficiencies are exacerbated by the truly dire living conditions in Gaza. With an estimated 150,000 housing units destroyed, and multiple areas currently under evacuation orders, very few people are still able to live in their homes. Many are living in overcrowded shelters (including schools and hospitals) or tents, which offer little protection from the summer heat or impending winter cold, and the coming rainy season will lead to even more misery for those living in makeshift structures. The poor and overcrowded conditions are not just uncomfortable but pose multiple health risks. For example, there have been nearly one million reported respiratory infections, easily spread in such crowded conditions and aggravated by exposure to cement dust and materials such as asbestos that are laid bare when buildings are destroyed. In addition to causing asthma and bronchitis, such exposures can lead to mesothelioma, a deadly form of cancer.
Perhaps most urgently, children’s inability to receive routine vaccinations coupled with the grim living conditions has led to the first cases of polio in Gaza in nearly three decades. The first recent case was diagnosed in a young boy who became paralyzed in his legs due to the disease. A widespread polio vaccination campaign was rapidly organized through a multilateral global effort, the first rounds of which were generally successful. However, the third round of vaccinations was delayed due to Israel’s bombardment and its constant displacement of people. When it finally got underway, Israel bombed a health facility that was administering vaccinations during a humanitarian pause. Four children were injured.
Destruction of a Health System
Israel’s assault on the health system in Gaza came swiftly after the bombing began in October 2023. In just the war’s first few months, most of Gaza’s hospitals were damaged from bombing. By mid-November 2023, half of hospitals were nonfunctional due to bombing or lack of fuel for generators, and human rights organizations were already condemning Israel’s “repeated, apparently unlawful attacks on medical facilities, personnel, and transport.”
Israel has issued evacuation orders to multiple hospitals, but such directives are impossible to follow due to the delicate condition of many patients and the lack of places for them to safely go. In late October 2023, the World Health Organization called Israel’s demand for the evacuation of 22 hospitals in the north of Gaza a “death sentence” for patients. As Israel has issued countless evacuation orders over the past year, this scenario has repeated itself. Other hospital workers preemptively left their facilities with their patients, as evacuation orders came closer to their vicinities—by late summer 2024, 84 percent of Gaza’s territory was under evacuation orders. Humanitarian organizations have attempted to erect field hospitals to deal with the demand, but as one Médecins Sans Frontières (MSF) physician put it, “You could put up 1,000 field hospitals, and that wouldn’t address a tenth of the needs in Gaza.”
Israel has raided and besieged multiple hospitals, with the Indonesian Hospital in late November 2023 among the first to suffer such assaults. Al-Shifa Hospital, the largest in Gaza, was raided multiple times, starting in mid-November after Israeli forces claimed Hamas had turned the facility into a “command center.” No evidence of this was offered. The largest raid of Al Shifa occurred in April 2024, when Israel besieged the hospital for two weeks. During the raid, multiple patients died, while dozens more, including unaccompanied children, were trapped with little food and water. Several health workers were killed, and others detained.
A recent Associated Press investigation of three hospital raids in late 2023—at al-Awda, Indonesian, and Kamal Adwan Hospitals—found “little or even no evidence of a significant Hamas presence.” At al-Awda, Israel did not even claim a Hamas presence existed, and reporters who asked the military spokesman why the hospital was raided received no reply. For the other facilities, Israel provided no evidence for the supposed tunnels, command centers, or weapons stores that it used as justification for the raids.
Even facilities that had been partially functional and able to support staff are now becoming nonfunctional due to lack of fuel for generators and medical supplies. Destroyed streets are making it impossible for ambulances to carry patients. The remaining hospitals are able to provide little more than first aid, with barely any treatments available for the tens of thousands in Gaza with chronic health conditions like diabetes, heart disease, and cancer. Today, there are no fully functional hospitals in Gaza and just 16 of the remaining 39 are partly operational, offering only the most basic of services. In early November 2024, Israel again bombed Kamal Adwan Hospital just weeks after raiding the facility, injuring staff and destroying remaining infrastructure, and leaving northern Gaza with almost no health services.
Systematic Assault on Healthcare Workers
Attacks on health care are not, of course, limited to assaults on physical structures. Within one year, Israel killed some 1,000 health workers, 85 Palestinian Civil Defense workers (who perform emergency rescue operations), and nearly 300 aid workers, most of whom were United Nations Relief and Works Agency (UNRWA) staff. In addition to attacking hospitals directly, Israel has killed medical staff while they were attempting rescues, such as the paramedics who had received Israeli permission to rescue Hind Rajab, a six-year-old girl who was trapped in her car with her family who had all been killed. Instead, the paramedics, as well as Hind, were killed.
Israel killed some 1,000 health workers, 85 Palestinian Civil Defense workers, and nearly 300 aid workers.
Indeed, Israel has completely flouted humanitarian law’s protections for health workers whose killing has significantly crippled health services across Gaza. This has left the remaining medical staff working nearly non-stop to provide care, including by sleeping at the hospital away from their families to avoid the danger inherent in traveling during wartime.
Unfortunately, hospitals are not safe places for the doctors and nurses of Gaza. The aforementioned raids have resulted in hundreds of Palestinian health workers being detained, with some released quickly but many held indefinitely and others forcibly disappeared, with their colleagues and families having no idea where they have been taken or if they are even alive. In December 2023, Israel kidnapped Dr. Adnan al-Bursh, the head of orthopedic surgery at al-Shifa Hospital, who was arrested at al-Awda Hospital after refusing to leave his patients during an evacuation order. Months later, reports emerged that he had been killed in Israeli custody. Dr. Iyad Rantisi, who had been the director of Kamal Adwan’s maternity department, suffered the same fate. He died six days after being detained by Israel.
In August, Human Rights Watch released a report detailing the horrific conditions of detained health workers from Gaza, including leaked photographs of the Sde Teiman detention facility. The report included accounts of beatings, prolonged cuffing and forced stress positions, denial of medical care, torture and sexual abuse, and poor living conditions. Most prisoners are never charged with any crime or even told why they are being detained. At least 300 Palestinian health workers have been detained in these conditions, and the raids continue: when Kamal Adwan Hospital was raided in late October 2024, 30 of the hospital’s 70-member staff were detained, including Dr. Mohammed Obeid, an orthopedic surgeon with MSF. Israel has not released any details of where these workers were taken or of their current state of well-being.
Blocking Humanitarian Access
Aside from creating disastrous conditions inside Gaza and making it nearly impossible for its health system to respond to crises, Israel has consistently made it difficult for humanitarian organizations to offer meaningful support to Gazans. Along with maintaining a siege that seriously impedes delivering food, water, medical supplies, and other needed goods, bombing and denying entry to aid convoys to Gaza, and killing aid workers, Israel has escalated its efforts to discredit and disallow some aid agencies entirely.
For example, after a physician published an article in the New York Times compiling the testimonies of dozens of foreign doctors who worked in Gaza, including treating multiple children with sniper shots to the head, Israel barred, without explanation, six health-related NGOs from entering Gaza, including those that facilitate medical missions from international physicians. While Israel has not permitted international journalists to independently enter Gaza, these physician testimonies pierce Israel’s arguments that it is operating lawfully, and the timing of the ban seemed to be an attempt to prevent such evidence from being shared.
Perhaps the most prominent example is UNRWA, the UN agency for Palestinian refugees that offers the bulk of health and education services in Gaza and that has, by far, the greatest ability to coordinate and implement aid efforts on the ground. For decades, Israel has worked to delegitimize and eliminate the agency. As its military campaign in Gaza expanded, so too did this effort. In January 2024, Israel accused several UNRWA staffers of being directly involved with Hamas’s October 7 attack. Israeli officials offered only unverified evidence, yet most of UNRWA’s funders, including the United States, stopped funding the agency. Months of investigations brought no evidence, and most donors, with the exception of the United States, resumed funding.
In late October 2024, the Israeli parliament took the unprecedented step of voting to declare UNRWA a terrorist organization and banning it entirely from Gaza within 90 days, a move that will severely limit if not eliminate the agency’s efforts to operate. It is unclear what this will mean for the humanitarian response effort in Gaza—while several countries expressed concern and opposition to the legislation, they have proposed no punitive action against Israel nor a plan for how to respond when the legislation takes effect in less than 90 days.
And Israel is denying people the ability to receive health care outside of Gaza, not just within the enclave. Because of Israel’s blockade, patients have long needed to apply for medical permits to transfer to a hospital outside of Gaza—often to the occupied West Bank, Israel, Egypt, or Jordan—especially for ailments like cancer or for advanced procedures. Currently, the United Nations estimates that about 14,000 patients, including 2,500 children, require medical evacuations for care. Since Israel seized Rafah in early May 2024, only 229 Gazans have been evacuated. The spokesperson for UNICEF summarized this harsh reality:
Children in Gaza are dying—not just from the bombs, bullets and shells that strike them—but because, even when ‘miracles happen,’ even when the bombs go off and the homes collapse and the casualties mount, but the children survive, they are then prevented from leaving Gaza to receive the urgent care that would save their lives.
An Expanding Front for Attacks on Health and an Unknown Future
Israel has destroyed the health situation in the Gaza Strip to a degree that makes it nearly impossible to imagine what rebuilding might look like, although some are already discussing the prospect. At the moment, however, the future is too uncertain, especially since Israeli government and military officials have given multiple indications that they plan to seize parts of Gaza permanently. What is certain is that the devastation wrought on Gaza’s health facilities—many of which Gazans had so painstakingly built after fighting endless restrictions—and on health personnel, many of whom studied outside of Gaza but returned to serve their people, will take generations to recover. And the health outcomes of more than a year of deprivation of food, water, medicine, and safety on an entire population are incalculable.
As Israel expands its war on health care to Lebanon, with at least 163 health workers killed there and dozens of hospitals damaged so far, it is clear the lesson learned in Gaza is that there is no consequence for Israel for violating what, rhetorically, had been among the most sacred principles of international humanitarian law: the protection of health facilities, health workers, and the health of affected populations. Israel has learned, and has shown the world, that the mere hint of a security justification, even when evidence is not supplied or is easily disproven, can grant a belligerent party near carte blanche to attack every aspect of civilian life. The tenets of the already fragile global system have been shredded in Gaza, leaving Palestinians to be murdered by the tens of thousands as the same countries supplying the weapons and protecting the perpetrators repeat the same hollow condemnations.
In such a time of grief, is there hope to be found? Perhaps there is in the halls of the very hospitals where so many violations have been documented. Al Shifa Hospital, which was left in near ruins after multiple Israel raids, has sought to rehabilitate salvageable parts of the hospital over the summer to be able to expand services, using the labor of volunteers and whatever pieces could be used from other destroyed buildings nearby. Other hospitals have made similar efforts, and health and civil workers continue, against all odds, to save lives. Despite the endless tragedies, it is important to acknowledge these heroic efforts, representative of an unending commitment to Palestinian life, and a reminder that resistance to elimination comes in many forms.
The views expressed in this publication are the author’s own and do not necessarily reflect the position of Arab Center Washington DC, its staff, or its Board of Directors.
Featured image credit: Anas Mohammed
