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As a team of public health researchers, we have been documenting the interconnected set of Israeli actions used to dismantle the Gaza Strip’s health system since October 2023. Far from the passive language of “humanitarian crisis” that is often used, our findings reveal a purposeful effort to collapse Gaza’s health sector that was already taking shape during the very first weeks and months of Israel’s military campaign.
Our research contributes to an important body of evidence – built on the foundations of the work and testimonies of Palestinians on the ground – for future justice, accountability, and restitution, including in the case brought by South Africa to the International Court of Justice charging Israel with the crime of genocide.
In any society, the health system is one of the institutions most closely linked to a population’s ability to survive and thrive. Using public health research to document the patterns of harm to a healthcare system provides a powerful tool for understanding how military policies translate into human consequences.
International observers, journalists, and humanitarian organisations have all played an important role in documenting Israeli violations in Gaza. However, public health research provides a distinct form of evidence. By combining data sources – such as mortality data, satellite imagery, and health systems monitoring – with analytic methods, including geospatial analysis and descriptive and inferential statistics, we have been able to assess not only the scale of civilian harm, but also the patterns through which health services and other critical civilian infrastructure were rendered nonfunctional.
Together, these findings help explain how Israel caused the collapse of Gaza’s health system, while also documenting the scale of death and suffering that followed.
Collapsing the system
One of the earliest indicators of the Israeli assault on public health in Gaza was the extraordinary civilian death toll generated by Israel’s aerial bombardment campaign.
In the first months after 7 October 2023, we analysed mortality data, verified by the Palestinian Ministry of Health, that revealed demographic patterns that differed substantially from previous military assaults on Gaza.
During major Israeli attacks in 2008-09, 2012, 2014, and 2021, women and children constituted between 30% and 41% of those killed. By comparison, between 7 October and 24 November 2023, they comprised approximately 67% of those killed.
Given Gaza’s demographic profile, which closely parallels the percentage of women and children killed in the first six weeks of the attacks, these findings suggested levels of civilian harm consistent with an indiscriminate bombing campaign, a war crime in and of itself. Beyond the immense human toll, the resulting mass casualties quickly overwhelmed hospitals already operating under siege conditions.
The destruction was not randomly distributed. Spatial analysis identified statistically significant clustering around critical civilian infrastructure, indicating that this infrastructure was likely targeted systematically.
At the same time, we documented widespread damage to the civilian infrastructure upon which health depends. Using satellite imagery and geospatial analysis, our team analysed patterns of destruction during the first six weeks of the Israeli assault. Damage was detected at more than 60% of health facilities, over two thirds of educational facilities, and more than 40% of water infrastructure sites. Importantly, the destruction was not randomly distributed. Spatial analysis identified statistically significant clustering around critical civilian infrastructure, indicating that this infrastructure was likely targeted systematically.
We also observed similar patterns of attacks in areas designated by the Israeli military as “safe zones” and along evacuation routes that civilians had been instructed to use. These findings indicate that – despite Israeli claims that it was taking steps to protect civilians – it was deliberately and repeatedly targeting people in the very places they had been directed to seek safety.
Hospitals themselves were subjected to particularly intense military activity, including bombardment and siege. Under the Geneva Conventions and customary international humanitarian law, hospitals and other medical units are entitled to special protections. That protection can cease only under a narrow exception: The hospital must actually be used, outside of its humanitarian function, to commit acts harmful to the enemy. Even if a hospital is being misused, loss of its special protection does not automatically make it lawful to bomb.
Return to Gaza’s Nasser Hospital: “Every single thing in the complex is a crisis”
After two and a half years of siege and blockade, the challenges staff and patients still face are extreme. Yet the world’s attention has moved on.
Israel’s public justifications for attacks on hospitals were that they had lost the legal protections typically afforded to healthcare personnel and infrastructure during conflict due to military activity in these facilities. In particular, Israel made several claims that hospitals it had bombed or raided were “command and control centres” for Hamas, while presenting little to no evidence to support such claims.
Furthermore, investigations by media as well as by prosecutors of the International Criminal Court assessed that Israel’s claims were, at best, exaggerated. It also quickly became clear that no hospitals were spared from Israel’s assault, casting more doubt on Israel’s claims.
Without being able to directly access the hospitals ourselves, we used geospatial methods to assess the proximity of large-scale bomb detonations to hospitals throughout Gaza. By overlaying publicly available crater data with hospital locations, we found that one quarter of Gaza’s hospitals had at least one US-supplied 2,000-pound bomb crater within the estimated lethal blast radius during the first six weeks of the military campaign, while more than 80% fell within ranges associated with infrastructure damage and injury.
These findings suggest that hospital facilities, patients, health workers, and surrounding civilian populations were routinely exposed to the effects of some of the most destructive conventional munitions used during the Israeli campaign – with no evidence presented that could possibly justify the devastation of Gaza’s health sector.
No hospital in Gaza remained fully functional by the end of October 2023. (...)These findings point to more than isolated disruptions; they reveal the rapid degradation of an entire health system.
Beyond physical destruction, the health system was further undermined by siege conditions, evacuation orders, and the collapse of other essential services. In partnership with the World Health Organization, we analysed data – collected throughout the first year of the assault – on the availability and functionality of hospital-level health services.
The findings showed that no hospital in Gaza remained fully functional by the end of October 2023. System-wide functionality fell below 40% within months and at times nearly three quarters of hospitals were classified as nonfunctional, unable to provide even basic health services. These findings point to more than isolated disruptions; they reveal the rapid degradation of an entire health system.
Israel’s campaign of erasure: The demolition of eastern Gaza
Analysis of satellite images points to a pattern of systematic destruction designed to lay the groundwork for annexation rather than reconstruction.
The role of public health research
Taken together, these studies document several interconnected mechanisms through which Gaza’s health sector was dismantled: the generation of mass casualties; the destruction of hospitals and other health infrastructure; damage to water and other civilian systems essential to population health; and the sustained degradation of health system functionality through siege and military operations.
These findings have significance beyond public health. They provide empirical evidence that can inform assessments of compliance with international humanitarian law, investigations into alleged war crimes, and broader probes into genocide and other mass atrocity crimes.
Alongside the lack of credible evidence that Palestinian militants used hospitals for military purposes, our findings also challenge official narratives that portray attacks on health infrastructure as isolated incidents or unintended consequences of military operations.
The role of health research in contexts of war and mass atrocity extends beyond measuring deaths and injuries. It can illuminate the relationship between political and military decisions and population health outcomes, identify systematic patterns of destruction, and generate evidence relevant to processes of accountability and justice.
In Gaza specifically, this research – situated within a growing body of literature documenting multiple aspects of Israel’s direct and indirect destruction of Gaza’s health system – has helped move the discussion beyond anecdote and accusation. It provides a rigorous record of how a health system was brought to collapse and what that collapse means for the population it served.
Edited by Eric Reidy.
