Violence in Palestine demands immediate resolution of its settler colonial root causes

Editorial on BMJ Global Heath

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The latest escalation of more than 100 years of violence in occupied Palestine has caused phenomenal levels of yet more suffering. This violence must end. The United Nations Office for the Coordination of Humanitarian Affairs reports that at least 3785 people are known to have been killed in besieged Gaza, 79 people killed in the occupied West Bank and 1400 people killed in Israel over the course of 12 days, since 7 October 2023.1 As of 19 October, approximately one million Palestinians and people of other nationalities have been internally displaced, many of whom are seeking refuge in overstretched designated emergency shelters and hospitals, several of which have been hit by Israeli airstrikes.1 This represents an increase in the number of internally displaced people in Gaza of more than 2000% in just 12 days.1 30% of all housing units in the Gaza Strip have been destroyed or rendered uninhabitable.1 Additionally, Palestinian workers from Gaza who were working in Israel have been beaten, detained and forcibly transferred to overcrowded facilities in the West Bank.2

The WHO has reported that at least 12 Palestinian health workers have been killed on duty in Gaza between 7 and 15 October, while the Palestinian Minister of Health Dr Mai Al-Kaila released a statement on 14 October stating that a total of 28 health workers have been killed by Israeli airstrikes.3 4 Casualty lists made available to the authors suggest this number could be almost twice as high. Four of those killed were Palestinian Red Crescent Society paramedics, whose marked ambulances were targeted in east and north Gaza on 11 October despite advance coordination with the Israeli military.5 UNRWA has also reported violence against its staff, confirming that at least 14 essential humanitarian personnel have been killed, as of 18 October.6 In Israel, an emergency medical technician working for Magen David Adom was killed on 8 October.7 ,1

These most recent, egregious healthcare-related attacks follow a long history of Israeli violence against health workers, the destruction of health infrastructure, the systematic obstruction of access to healthcare,8 and the implementation of eliminatory settler colonial strategies by the Israeli occupation that aim to increase morbidity and mortality (such as the de-development of Palestinian health and other essential services,9 exerting full control over—and now withholding—the water and electricity supply to the Gaza Strip10 and the deliberate targeting of limbs leading to traumatic limb loss and disability),11 in occupied Palestine.12

With this in mind, it is impossible to divorce the violence of recent days from the long history of the Israeli occupation of Palestine. This history is marked notably by the 1948 Nakba that involved the violent displacement of more than 700 000 Palestinians from over 400 villages and towns by Israeli settlers,13 14 and the preceding British colonial occupation of Palestine. Since 2007, a complete blockade has been enforced by Israel around the Gaza Strip, while the West Bank has been under occupation by Israel for more than 55 years following the Six Day War in 1967. As Israel has maintained its occupation of the land and has continued to oppress and dispossess the Palestinian people, Israeli politicians have enabled the construction of hundreds of illegal settlements in the West Bank and provided military protection to settler-led pogroms, property destruction and violent—often deadly—attacks.15 16

The WHO’s Surveillance System for Attacks on Healthcare has documented 5316 distinct incidents related to attacks on patients, healthcare workers or health infrastructure in 20 countries and territories since February 2017.17 A staggering 1519 (28.6%) of these incidents were perpetrated against the Palestinian population, Palestinian health workers and the Palestinian health system. One hundred and eleven Israeli attacks on Palestinian health workers and health services occurred between 7 and 15 October 2023 alone.3 Among a litany of atrocious attacks, on 13 October, the Al-Durrah Children’s Hospital was evacuated after reportedly being hit by white phosphorus shells fired by the Israeli military.18 Human Rights Watch has verified footage of the use of white phosphorus munitions in Gaza and Lebanon by Israel, which may constitute war crimes. Despite verification, the Israeli military has denied use of such chemical weapons.19 On the evening of 17 October a missile strike at Al-Ahli Hospital in Gaza City killed at least 471 people. The hospital was operational and treating patients at the time, while internally displaced people had sought shelter close to the facility.20

The Al-Ahli Hospital missile strike represents one of the most horrific incidents at a healthcare facility in our collective history. While the origin of the missile strike remains to be determined, its impact is of a magnitude greater than the heinous US military bombing of the Kunduz Trauma Centre in Afghanistan in 2015, which killed 42 patients, caretakers and MSF staff.21 In the aftermath of the Kunduz bombing, the UN Security Council unanimously adopted Resolution 2286 in 2016, which condemned acts of violence against the wounded, sick, and health and humanitarian workers; demanded compliance with international law; demanded safe passage for health and humanitarian workers; and emphasised state responsibility to ‘to end impunity and to ensure those responsible for serious violations of international humanitarian law are held to account’, among other commitments.22 MSF International President Joanne Liu spoke passionately at the same UN Security Council meeting, reiterating that ‘seeking or providing healthcare must not be a death sentence’, while calling on UN Security Council members to ‘make this resolution save lives’.23

On the evening of 18 October, the United Nations Security Council could not even approve a resolution that sought to condemn all violence against civilians; call for the protection of medical and humanitarian personnel; and urge the continuous and unhindered provision of essential goods and services needed to sustain life—water, food, medical supplies, electricity, and fuel—among other urgently needed commitments. The resolution was vetoed by representatives of the United States government.24 While we acknowledge a long and enraging history of a lack of accountability following attacks on civilians, health and humanitarian workers and essential infrastructure, it is both morally and legally necessary to reaffirm the protection of health workers and health services in conflict. Legal safeguards are codified in several Geneva Conventions, breaches of which constitute violations of international humanitarian law. The failure to uphold these protections continues to undermine any sense that these international legal frameworks function to serve our collective humanity.

It is of additional, grave concern that on the evening of 12 October, the Israeli military issued a 24-hour warning that more than 1 million Palestinians living in northern Gaza must leave, failing which they risked more of the indiscriminate violence caused by the ongoing Israeli siege and bombardment. This displacement order was extended to staff and patients in hospitals providing lifesaving health services in the northern Gaza Strip, with no recognition of their protected status under international humanitarian law.25 In addition, the Rafah border crossing in southern Gaza into the Sinai Peninsula, Egypt, remained closed as of 19 October following Israeli bombardments and the subsequent intensification of Egyptian military patrols, leaving Palestinians and people of other nationalities in the densely populated Gaza Strip with nowhere to seek safety, and no access to Gaza for essential humanitarian assistance. The threat of forced displacement without any guarantee of safety or return amounts to a war crime.26 These threats are comparable to calls for the expulsion—or ‘forced transfer’—of the Palestinian people from their land, which have been central to Zionist expansionism and advocated by several Zionists prior to and following the formation of the state of Israel in 1948.27

Any credible commitment to—and movement for—health justice must see both the ongoing and longstanding violence against health workers and attacks against healthcare in this context as an extension of the systematic campaign of violence and oppression against the Palestinian people, and must interrogate its root causes accordingly.

The horrific escalation of violence over the course of the last two weeks must end. We join the calls of millions of people worldwide demanding an immediate end to all hostilities in occupied Palestine. Urgent and long overdue, principled regional and international engagement, a steadfast commitment to—and the meaningful application of—international law, along with newfound respect for fundamental human rights, are needed now to ensure the immediate de-escalation of the threat posed by Israel to the lives of millions of Palestinian people.

Data availability statement

All data cited is publicly available, with the exception of the health worker casualty list. Given the sensitivity of this information, requests for further circulation will be considered only under very specific circumstances.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Not applicable.


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  • Correction notice The description of the Al-Ahli hospital explosion has been updated to reflect best understanding of the event at the time that the article was published.
  • Contributors JS conceived of this commentary, and prepared a first full draft. All authors reviewed the draft and provided edits and comments. JS finalised the manuscript following the review process.
  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
  • Competing interests JS is a Medact trustee and maintains a regular direct debit with Medical Aid for Palestinians. Rasha Khoury is an unpaid member of the Doctors Without Borders/MSF-USA Board of Directors. LH is Palestinian, lives in Palestine and has friends and family across all of Palestine including Gaza. He therefore has an interest in his people not being subjected to genocide.
  • Provenance and peer review Commissioned; internally peer reviewed.
  • At the time of writing, information pertaining to fatalities has emerged from several sources, and has not been disaggregated by professional affiliation. As such, there may be some overlap in fatalities counted by different sources. We encourage readers to read this data as an indication of the scale of violence, and to refer to confirmed deaths by specific organisations as an indication of particularly egregious violations against protected cadres of health and humanitarian workers.

Authors: James Smith1,Edwin Jit Leung Kwong2,Layth Hanbali3,Sali Hafez4,Amy Neilson5,Rasha Khoury6

Featured image: A medic sits with his head in his hands at al-Ahli hospital after the blast. Photograph: Mohammed Saber/EPA published in the Guardian

Published in BMJ Global Health October 2023

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