On September 17 and 18, 2024, a coordinated Israeli attack turned pagers and walkie-talkies in Lebanon into explosive devices, killing at least 42 people and injuring thousands more in Beirut and elsewhere. United Nations experts quickly deemed the indiscriminate violence—which occurred while many who owned the devices were at home, out shopping, or doing other everyday tasks—a violation of international law, noting that “at the time of the attacks there was no way of knowing who possessed each device and who was nearby.” Indeed, while Israel claimed the targets belonged to Hezbollah, the explosions killed two children and left many other bystanders with significant injuries.
The attacks had a devasting impact on 150 hospitals across Lebanon. As Dr. Elias Warrak, founder and medical director of the Advanced Eye Care Hospital, told National Public Radio,
The first day, we left the operating room around 5 in the morning, and the second day, we left at around 2 in the morning…all of the casualties, we requested to do a CT scan for the brain and the orbits, because some of the patients, they had intracranial shrapnel. They had some injuries to the brain, so they had to be operated on by neurosurgeons, and then we went in as an ophthalmology team just to treat their eyes…there is not a single casualty who didn’t lose at least one eye.
After nearly a year of Israeli bombardment, blockade, and other catastrophic damage to the Gaza Strip in what is increasingly being recognized as a genocide, the pager attacks marked a shocking escalation of the intermittent bombing campaign of Lebanon that Israel launched since soon after Hamas’s October 7, 2023 assault on the Zionist state. Two weeks after the pager detonations, Israel began a ground invasion of Lebanon. By the time that Israel and Hezbollah agreed to a ceasefire on November 27, 2024, Israel’s latest Lebanon war had killed some 4,000 people, displaced more than one million others, and significantly damaged civilian infrastructure, including the healthcare system through apparent direct targeting of health workers.
Healthcare in Lebanon
After gaining independence from France in 1943, Lebanon began the difficult process of building up a public health system under the newly established Ministry of Health and Social Affairs. Previously, healthcare infrastructure had been concentrated in larger cities and usually associated with religious or military organizations and delivered through private facilities.
Lebanon’s initial public health efforts were focused on limiting the spread of infectious diseases. In the following decades, a network of public health services expanded during a period of economic growth and the flourishing of many sectors of the country. Despite many challenges, Lebanon managed to develop the best health system in the Arab world.
The civil war (1975-1990) set back the health care system significantly and triggered multiple negative trends that continue to this day. As public facilities were targets of attacks and faced other operational challenges, private facilities expanded government spending due to deficiencies in the public health system.
At the same time, significant need led to the expansion of a philanthropic sector to absorb many of the public health system’s functions. Along with the establishment of parallel health care delivery systems, diminishing the role of public health, the health system became less proactive and preventative and more reactive and curative. Although the system began to be rebuilt after the civil war, it never fully recovered.
Lebanon was the site of multiple military campaigns by Israel, which were devastating to the health system.
Following the war, Lebanon was the site of multiple military campaigns by Israel, most notably in 1996 and 2006, which were devastating to the health system. Along with the civilian death and injury toll from Israeli attacks, many people were displaced, forced to live in unsanitary and underserved locations. Israel damaged multiple health facilities and its bombing of roads made travel difficult for health personnel and ambulances. In 2006, for example, Israel bombed Tibnin General Hospital in the south as it sheltered thousands, as well as Red Cross sites, killing medical staff members and destroying ambulances.
During the 2006 war, hospitals had to revise triage guidelines to preserve beds and equipment, and had difficulty serving displaced people and patients with chronic ailments like cancer. After the fighting stopped, Lebanese health officials undertook vaccination campaigns to quell the spread of infectious diseases such as polio and measles. The mental health toll was also significant. And for years, unexploded ordnance left by the Israeli military caused injury and death, as did the environmental toll of Israel’s bombing of oil tankers, fuel stations, and industrial factories.
In 2019, Lebanon entered another period of deterioration that included devastating forest fires, anti-government protests amid corruption and a spiraling economic crisis, and, in 2020, an explosion at the port of Beirut that seemed to punctuate the country’s looming status as a failed state. These events exacerbated an economic collapse that led to massive inflation as well as shortages in basic goods like fuel and medical supplies.
These shortages had lethal consequences. For example, it is believed that a fuel shortage at the American University of Beirut Medical Center (AUBMC) in 2021 contributed to the deaths of 40 adults and 15 children who were on ventilators. The economic crisis forced many Lebanese to avoid seeking medical care altogether, as the average salary dropped to just $72 per month while a regular check-up costs at least half that amount.
Amidst the economic crisis, the rationing of care became more common. As one health expert observed, “priority was given to high-risk patients and a person with a wasta [using influential connections for personal benefit] or someone who is potentially more well off.” Because doctors were unable to work effectively or were no longer getting paid, thousands left the country, including a reported 40 percent of emergency personnel at the AUBMC, the country’s largest medical center.
It is in this context that Israel’s latest assault on Lebanon began, after Hezbollah attacked Israel on October 8, 2023, in solidarity with Hamas. Lebanon’s health system, already fractured and overburdened, would soon face one of its most challenging periods yet.
Attacks on Healthcare in Lebanon
The past year has featured unprecedented Israeli violence against Lebanon’s health infrastructure and personnel.
According to the World Health Organization (WHO), 226 healthcare workers were killed and 199 wounded between October 7, 2023, and November 18, 2024. As it does in Gaza regarding purported Hamas targets, in Lebanon Israel justifies strikes on health workers and facilities by claiming that Hezbollah uses ambulances to transport militants and hospitals to store weapons and cash. However, investigations found no evidence for such claims. And even if medical personnel are affiliated with Hezbollah, this does not render attacks on them justified.
On just one day in early October 2024, Israeli airstrikes killed at least 28 on-duty paramedics. Fear of being attacked led many other health workers to avoid going to work, since strikes targeted health facilities as well as ambulances in transit. Some facilities even allowed the families of medical staff to live at their workplaces so that employees could work longer shifts without needing to travel home.
Fear of being attacked led many other health workers to avoid going to work.
Of the 137 attacks on healthcare documented by WHO, 47 percent killed at least one health worker or patient—a higher proportion than in any other active conflict today, including Gaza and Ukraine. Human rights groups documented multiple apparent war crimes, including unlawful strikes on paramedics at a civil defense center in central Beirut on October 3, 2024, and an ambulance and a hospital in southern Lebanon on October 4, killing 14 paramedics.
Strikes near hospitals were also highly damaging. For example, in late October, with no warning, Israel bombed near the Rafik Hariri University Hospital, Beirut’s largest public health facility, killing 13 people and injuring almost 60 more. The precarious conditions led many facilities to close entirely. Just weeks after Israel’s aerial campaign escalated, almost half of the 207 primary health care centers in targeted areas were forced to close. By late November, 10 percent of the country’s hospitals were nonfunctional due to evacuation orders, bombing, or lack of supplies. Some governorates Israel deemed to be Hezbollah strongholds were particularly targeted; the Nabatieh governorate in the south, for example, lost 40 percent of its hospital bed capacity.
Israel’s bombing campaign also diminished resources in facilities that were already stretched for medical supplies and equipment. Some hospitals had to ration electricity, such as the Nabih Berri government hospital after an airstrike destroyed a power line. While hospitals have generators, shipments of the needed fuel were delayed due to insecurity of transport amid unpredictable bombings of roads. Attacks also limited aid efforts, such as by preventing the WHO from delivering a large air shipment of medical supplies. Much less efficient alternate routes via land or sea had to be explored by suppliers.
Unprecedented Strain on a Weakened Health System
Prior to Israel’s 2024 military campaign, health care providers at Lebanon’s hospitals used their knowledge from previous wars to prepare for what they knew could be a lengthy period of violence and siege.
At Rafiq Hariri University Hospital, such preparations included instituting more efficient triage systems for critical patients, preparing specialized facilities for washing away white phosphorus used by Israel, revising security systems to prepare for an influx of patients’ families, and training staff to temporarily convert areas of the hospital to be able to conduct more trauma surgeries. The hospital director indicated that in the event of an Israeli siege, his facility could remain functional for ten days before needing more supplies. The WHO preemptively sent health facilities across Lebanon 32 tons of medical supplies to support these preparation efforts.
Yet the scale of Israel’s attacks pushed Lebanon’s health sector to the limit. For example, the pager attack challenged the capabilities of even the country’s most experienced practitioners and well-equipped hospitals. Patients were brought from all around the country to the larger hospitals in Beirut because smaller hospitals filled up immediately.
As a physician at AUBMC described, “Usually in mass casualties, you have a small percentage that are really high acuity.” This allows facilities to prioritize cases that need immediate care, while others can be admitted and treated over time. In the case of the pager and walkie-talkie attacks, all patients required immediate care to remove shrapnel from their bodies, to save their eyes, or to reconstruct hands that had lost fingers. In the days following the attacks, Israel intensified airstrikes, leaving many more thousands injured and requiring immediate treatment. Lebanon’s health staff worked around the clock to save lives, but the toll was substantial, with many workers requesting time with a psychiatrist to help them cope with all the horror they had witnessed.
The WHO estimates that one in four traumatically injured people will require long-term rehabilitation.
The strain on Lebanon’s health system will continue for years. According to a WHO representative, “The physical destruction is similar to what you see after an earthquake–and that has resulted in complex injuries, open wounds and fractures. And since the treatment provided during the war was often not optimal, the injured end up needing multiple surgeries to prevent complications and disabilities.” The WHO estimates that one in four traumatically injured people will require long-term rehabilitation, including specialized treatments and prosthetics. Lebanon lacks the needed facilities, equipment, and specialized providers like reconstructive surgeons, eye doctors, and physiotherapists to meet the demand.
Israeli Impunity for Healthcare Destruction Transcends Borders
Any accounting of Israel’s military behavior over the past several decades would include hundreds if not thousands of incidents of attacks on health care. Its utter destruction of the health system in Gaza, part of its broader campaign to make life impossible in much of the besieged territory, has broken all precedent of military response, especially for a military supplied and enabled by the world’s most powerful countries. It is thus expected that, after facing no consequences in Gaza, Israel will continue to target and limit the functionality of health facilities in Lebanon.
The precarity of Lebanon’s health system after decades of war, government failure, and multiple other crises already posed significant challenges to its ability to respond to the needs of its population. Damage to multiple health facilities and the killing of and threats of violence against health workers has further eroded the country’s capacity. The damage will have long-term repercussions—and there is no guarantee that the violence is over, as Israel has already violated the ceasefire multiple times.
Protections for health workers and facilities are among the most heavily enshrined principles in international law and norms relating to war. Yet Israel has continuously violated these protections, and its allies have shown that they will accept Israel’s security justifications, regardless of whether credible evidence is presented. Israel’s expansion into Lebanon and its attacks on health infrastructure are the latest tragic examples of the failure of the international community to hold perpetrators of crimes accountable, amounting to a tacit endorsement of such crimes. For Lebanon, an end to Israel’s violence is just the first step needed to rebuild a health system that used to be the envy of the region.
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: Shutterstock/Mohammad Kassir
