In both Gaza and Lebanon, Israel’s attacks on hospitals and health care are part of a deliberate effort to collectively punish and depopulate large geographic areas.
In early October, Shoshan Hassan Mazraani, the head emergency department nurse at the Marjayoun hospital in southern Lebanon, was drinking coffee at work when she saw an Israeli strike hit without warning “directly on the ambulances” outside. The attack killed seven paramedics and wounded five others. The same day, Israeli strikes repeatedly hit Salah Ghandour Hospital in the nearby town of Bint Jbeil. In that assault, nine hospital workers were injured, several critically.
“The hospital was struck three times,” the facility’s director, a physician named Moanes Kalakish said later. “One shell struck the on-call room and two shells struck the paramedics’ waiting room, [both] inside the hospital.”
In the weeks since, Israeli attacks have struck medical systems across Lebanon, hitting hospitals, ambulances, and clinics as part of an aerial assault and invasion that has now killed more than 3,000 people, including over 150 health care and rescue workers, in the past twelve months.
Two reports issued recently, one from Human Rights Watch (HRW) and another from CNN, detail the pattern of attacks on the Lebanese health care system. HRW, in its report, concluded that the Israeli strikes on the Marjayoun and Salah Ghandour hospitals, along with another separate strike on a rescue center in Beirut, all constitute likely war crimes. In total, HRW reported that Israeli attacks across Lebanon have hit a total of 158 ambulances and fifty-five hospitals. In a separate analysis, CNN found that in just the first month of the escalating offensive in Lebanon, Israeli strikes hit thirty-four hospitals and 107 ambulances, killing 111 emergency medical technicians.
The Israeli assault on health care in Lebanon is increasingly widespread, affecting the delivery of care throughout the country. In one single twenty-four-hour period in October, Israeli forces killed more than twenty-eight on-duty medics nationwide, forcing thirty-seven health care facilities to shut down and three hospitals in Beirut to evacuate. Nearly half of the country’s primary care centers have now been forced to close, and, according to CNN’s investigation, around 20 percent of all the hospitals nationwide have been damaged by Israeli strikes in the course of just a single month.
In the words of Imran Riza, the United Nations (UN) deputy humanitarian coordinator for Lebanon, the devastation has left the health system “on the brink of collapsing.” The World Health Organization (WHO) representative in Lebanon, Abdinasir Abubakar, assessed that “it’s just a matter of time until the system actually reaches its limit.”
The specter of the American-backed genocide in Gaza looms large over this unfolding violence, as Israeli leaders have made clear that the devastation in occupied Palestine should be understood as a threat to civilians in Lebanon. At the outset of the invasion, Israeli prime minister Benjamin Netanyahu warned of “destruction and suffering like we see in Gaza.” “What we are doing in Gaza, we can do in Beirut,” the Israeli defense minister Yoav Gallant said last November. Israeli forces, in his words, could “copy and paste” their methods.
Those methods developed in Gaza include deliberate and systematic violence against the medical system and health more broadly. In Gaza, Israeli forces have killed around a thousand Palestinian health care workers and bombed nearly every single hospital. An independent UN commission concluded in October that Israel “has implemented a concerted policy to destroy the health-care system of Gaza” and “deliberately killed, wounded, arrested, detained, mistreated and tortured medical personnel and targeted medical vehicles,” constituting multiple war crimes and crimes against humanity, including the crime of extermination. In July, a group of eleven independent UN special rapporteurs and experts found that Israel was engaged in an “intentional and targeted starvation campaign against the Palestinian people,” amounting to “a form of genocidal violence.” These efforts have been so total and so transparently deliberate that they have been described variously as a “War on Hospitals,” a “War on Health,” and an “Epidemiological War,” eventually demanding the invention of a new term to describe the carnage: medicide.
Strategy of Attack
Violence against health has existed for as long as armed conflict, and it serves identifiable strategic purposes. In Perilous Medicine: The Struggle to Protect Health Care from the Violence of War, human rights lawyer Leonard Rubenstein identifies several of these rationales. Militaries often attack health care to deny their enemies medical care, weakening their fighting capacity. Sometimes, belligerents commit violence against health care incidentally, for instance when attacking large areas indiscriminately.
In other cases, combatants may seek to exploit medical and humanitarian protections to engage in military maneuvers. This, for instance, is what happened in January, when Israeli commandos dressed up as medical workers to sneak into a hospital in the West Bank and kill a wounded man in his bed. It is also what happened in June, when Israeli — and possibly American — forces used a humanitarian aid system to access Nuseirat refugee camp in a hostage rescue operation that killed more than two hundred Palestinians.
While several of these rationales are clearly relevant to Israeli violence against health care over the past year, the rampant targeting of hospitals and medical workers is most consistent with another logic recognized by Rubenstein:
[S]trategically destroying or manipulating access to health care to entire populations or subpopulations through violence against, threats to, or interference with health assets, health workers, and health services. The use of this logic is often tied to attacks on civilians and civilian infrastructure generally, to demonstrate the futility of support for an opponent through collective punishment, or advance territorial aims by forcing population movement.
Collective punishment and forced expulsion of populations are cornerstones of Israeli violence in Gaza and Lebanon, and these rationales help explain the systematic attacks on health care still underway. With more than a quarter of Lebanon currently under Israeli military evacuation orders, many dozens of health care facilities are located inside areas that are being forcibly displaced. Entire towns in southern Lebanon have been almost entirely destroyed by Israeli forces, raising fears that Israel is attempting to prevent civilians from ever returning to these border areas, creating large “buffer zones” of empty land. In Gaza, almost the entire population of around two million people has been forcibly displaced multiple times, crowded again and again into shrinking ghettos that are routinely subjected to deadly bombardment.
A health care system poses a significant obstacle to any effort to uproot civilians. In addition to being part of the basic infrastructure that makes an area inhabitable, hospitals are also places of refuge and resource distribution in times of war and instability. As a result, they are often targeted in order to drive out local populations. As Rubenstein notes, in modern conflicts stretching from Liberia in 1989–2003 to South Sudan since the 2010s, “hospitals and clinics became places for opportunistic killing and armed groups denied access to hospitals and clinics as one element of leverage to force population movement.”
This pattern is increasingly clear in Lebanon and well-recognized by medical workers caring for the sick and wounded under Israeli bombardment. Abdul Nasser, a general surgeon at one barely functioning hospital in southern Lebanon, described the relationship between violence against health care workers and forcible displacement succinctly early in the Israeli invasion. “As soon as the doctors leave, then no one will stay in my city. And once people leave, it is very difficult to come back,” he said around the beginning of October.
Firass Abiad, who is a physician and also the Lebanese health minister has described this pattern too. Attacks on hospitals, he said, have been so widespread that many patients “are now afraid to come to the hospital.” In late October, after the Israeli military announced a total evacuation order for the city of Baalbek in eastern Lebanon and began shelling the area, another physician, Abbas Shoker, who is the director of the local government hospital, took to the airwaves to reassure the public that “damage to the hospital is minor . . . and our operations will not be disrupted.”
Throughout the campaigns in Gaza and Lebanon, Israeli military officials have justified their repeated attacks on hospitals, ambulances, and other medical resources with accusations that they are being used for military purposes. Most famously, the Israeli military released a computer animation about a year ago depicting what it claimed was an elaborate Hamas facility beneath the largest hospital in Gaza, Al-Shifa. Both Israel and the United States variously described the hospital as “the main headquarters for Hamas’ terrorist activity, ” a “command-and-control node,” and “perhaps even the beating heart” of Hamas operations. The hospital has now twice been invaded by Israeli forces, with almost nothing of significant military value found at the site. Many patients and health care workers were nevertheless kidnapped or killed, and the facility was almost completely destroyed. In the words of Abu Saada, the acting chairman of the hospital, “the Al-Shifa Medical Complex is out of service forever.”
Spiraling Devastation in Gaza
In northern Gaza, this horrific pattern has intensified to an unfathomable degree amid an apparent campaign of straightforward ethnic cleansing and extermination. There, hundreds of thousands of Palestinians have been almost completely besieged by Israeli forces for nearly a month, deliberately cut off almost entirely from food, water, and medicine, in what Palestine’s UN envoy has called a “genocide within a genocide.” Despite Israeli evacuation orders, Médecins Sans Frontières has reported that in some areas “nobody is allowed to get in or out — anyone who tries is getting shot.” On November 1, the heads of fifteen UN and humanitarian organizations, including the World Health Organization, UNICEF, and the World Food Programme, warned of “apocalyptic” conditions, concluding that “the entire Palestinian population in North Gaza is at imminent risk of dying from disease, famine, and violence.” The next day, Israeli forces attacked a UNICEF polio vaccination center and the personal vehicle of a UNICEF staff member.
Increasingly, the last three semi-functional hospitals in the area have become epicenters of this spiraling devastation. Those three facilities — Al-Awda, Indonesian, and Kamal Adwan — have all been besieged and raided previously by Israel in a series of harrowing attacks. In the past month, violence against the three hospitals as well as the health care workers and patients inside them has intensified. According to the head of the WHO, each has come under direct Israeli fire in the past several weeks.
In the most extreme instance, Israeli troops stormed Kamal Adwan again in late October, occupying the hospital for days. Israeli forces killed at least one doctor and detained more than thirty medical personnel. According to another WHO official, almost the entire medical staff was eventually captured and deported, leaving a single pediatrician as the only physician in the whole hospital. In reviewing the series of Israeli attacks on these three hospitals, the Associated Press concluded that “Israel has presented little or even no evidence of a significant Hamas presence” at any of the facilities.
Israel’s expanding attacks on health in Lebanon must be understood alongside these devastating attacks on health care, which have come to exemplify the intensifying genocide in Gaza. This point is not lost on those on the ground in Lebanon. In late October, when the Israeli military published a computer animation depicting what they claimed was a Hezbollah bunker filled with money beneath Al-Sahel hospital in the suburbs of Beirut, the echoes of Israel’s accusations against Gaza’s Al-Shifa were obvious, and the hospital was evacuated, for fear of an impending Israeli attack. Later that night, the largest public hospital in Lebanon, the Rafik Hariri University Hospital, suffered major damage in an Israeli air strike. Over the next several days, a series of international journalists were invited to Sahel, finding nothing of interest beneath the hospital.
The flimsy propaganda justifying the relentless targeting of health cannot be allowed to obscure the deeper truth, which is that Israel will continue to attack hospitals and health care workers until it is forced to stop, because doing so has proven to be an effective way to drive communities from their homes.
This, too, is clear to those tending to the sick and wounded in Lebanon. Discussing his work in an ambulance with journalists recently, Bachir Nakhal, a Beirut-based volunteer rescue worker, said it clearly: “I fully believe this is purposeful targeting of emergency services because Israel’s strategy is not just to target civilians, it’s to maim them, to render them unable to work, to render whole regions unlivable.” Weeks later, the Lebanese health minister shared a similar assessment of the replication of attacks on health in the past year: “It’s clear that this is premeditated, that this is a state policy that Israel is following, whether in Gaza or in Lebanon.” In a separate interview, he shared his fear that “without any clear end to this conflict and only escalation options on the table, that the course of events will follow what we have seen in Gaza.”
It is often said that much of the art of medicine is pattern recognition. American-backed Israeli violence against the health care system in Lebanon is not fundamentally distinct from the carnage still unfolding in Gaza. In both cases, attacks on hospitals and health are part of a deliberate effort to deliver collective punishment and depopulate large geographic areas. The strategy has been seen in other armed conflicts before and presents no great mystery now. The pattern is clear enough to see for anyone who cares to look.