Clashes at Gaza hospitals raise stakes for Israel

Israel is pushing to root out Hamas at hospitals in Gaza City despite calls to avoid firefights at health care sites to prevent compounding a dire humanitarian crisis.

Israel says Hamas is using the medical facilities as command bases, making them a legitimate military target — and the U.S. shared declassified intelligence Tuesday bolstering those claims.

But clashes around the hospitals are endangering patients, including young children, and fueling concerns that Palestinian civilians caught in the crossfire will soon lack any comprehensive treatment facilities in Gaza City.

With the world watching, Israel is trying to convey a message that it must destroy Hamas wherever the group operates and mitigate harm to civilians at hospitals.

Hamas likely wanted to force Israel to conduct a delicate operation around medical facilities, said Joel Zivot, an associate professor of anesthesiology and surgery at the Emory School of Medicine.

“I would imagine that from Hamas’s perspective, this was a strategic decision. It was a decision to put these places inside of hospitals because of this very problem of trying to go in and to attack a military site,” he said.

“I have lots of sympathy for the patients and the injured and the innocent people,” Zivot continued. “But the tragedy here is that Hamas inculcated itself into these buildings, and therefore, they became military targets.”

International humanitarian law under the 1949 Geneva Convention prohibits attacking hospitals and other medical sites unless they are being used for military operations, at which point they become a legitimate target. 

That’s true if even one fighter launches a single rocket from a hospital, which transforms it from a hospital into a military base. But attacks are still considered unlawful if they are indiscriminate or disproportionate, such as launching an explosive device in a densely populated area.

Since the war started on Oct. 7, there have been 137 attacks on medical sites, according to the World Health Organization (WHO), and more than 500 people have died in those attacks, including 16 medical workers.

The WHO has called for an immediate halt to military operations at hospitals, while human rights groups are sounding the alarm about a potential violation of war.

Paul O’Brien, executive director of Amnesty International USA, said in a statement to The Hill that his human rights organization has documented “unlawful” and “indiscriminate attacks,” including bombings on hospitals, that should be investigated as war crimes.

Human Rights Watch (HRW) in an investigative report Tuesday accused Israeli forces of killing and wounding people at Al-Shifa Hospital, Indonesian Hospital and other health care sites.

“Israel’s repeated attacks damaging hospitals and harming healthcare workers, already hard hit by an unlawful blockade, have devastated Gaza’s healthcare infrastructure,” said A. Kayum Ahmed, a special adviser on the right to health at HRW, in a statement.

Israel is now fighting around several hospitals in Gaza City, including Al-Shifa, which it claims is the site of the main Hamas command base. 

The Israel Defense Forces (IDF) signaled even before entering Gaza City that it needed to take out Hamas operations at Al-Shifa, which is also the largest hospital in the city.

But even if Al-Shifa is a major base of operations, Hamas is a decentralized network that does not have one central command node, said Michael Nagata, a senior fellow on national security at the Middle East Institute (MEI) and a retired U.S. Army lieutenant general.

“The notion that they are going to completely destroy Hamas, from my point of view, is unachievable,” he told reporters during a press call. “Some elements of Hamas will survive; they will live to fight another day.”

Nagata added that Israel relies on external support from allies and could face a “reckoning” over how it carried out its war against Hamas if attacks continue to kill and injure a large number of civilians.

“If they lose enough international support all of this becomes impossible,” he said.

The fighting has forced hospitals to the brink as they struggle with electricity, water and food access and to treat wounded patients. At Al-Shifa, hospital officials reportedly claimed they were digging mass graves.

Israeli soldiers have tried to take steps to minimize casualties at health care sites as it carries out its retaliatory war against Hamas for killing 1,200 people in a deadly Oct. 7 surprise attack. 

Before moving in, Israel ordered the evacuation of 22 hospitals in Gaza City and opened evacuation corridors, although it can be extremely difficult for some patients and staff to leave quickly.

Other Israeli soldiers are providing incubators to the pediatric ward at Al-Shifa. And Israel attempted to deliver 300 liters of fuel to the hospital but later said Hamas intercepted the shipment.

Mick Mulroy, a former U.S. deputy assistant secretary of Defense for the Middle East who is now at MEI, said the daily tactical pauses should also be used to evacuate patients out of the hospitals with ambulances.

Mulroy also said Israel is caught in a complex battle.

“You have newborns that are in ICUs, and you’re trying to defeat the enemy, trying not to get killed and trying to minimize casualties,” he said in a press call. “It is ultimately Hamas that has caused this, but it is the IDF … that has to do everything it can to avoid these civilian casualties.”

As questions mount, the IDF is trying to present evidence of its claims about command sites at hospitals, which Hamas and Palestinian health officials deny.

One video allegedly shows Hamas tunnels near the Rantisi hospital. Others have shown apparent Hamas military planning documents, weapons and rooms underneath hospitals to hold hostages and film videos.

At the al-Quds hospital, Israel this week released a video of what appears to be a militant with a rocket launcher near the building. Israeli forces claimed to have killed 21 militants at the hospital who fired from the entrance.

“This is Hamas,” said IDF spokesperson Rear Adm. Daniel Hagari in a video showing purported evidence of weapons in a hospital basement. “The world has to understand who Israel is fighting against.”

Along with Hamas, Palestinian health officials at the Hamas-run hospitals dispute the claims that militants operate out of the health care sites.

The U.S. has backed Israel’s claims, though it has not described how it collected its intelligence on the matter. 

Pentagon deputy press secretary Sabrina Singh said Tuesday that Hamas is using the hospital sites to “conceal and support” military operations and to hold hostages. But Singh said hospitals should continue to treat civilians and “should be protected.”

“We do not want to see a firefight in the hospital where there are innocent civilians,” she told reporters at a briefing.

At the White House, President Biden on Monday called for more protection of the hospitals.

“My hope and expectation is that there will be less intrusive action relative to hospitals, and we remain in contact with the Israelis,” he said.

Russell Berman, a senior fellow at the Hoover Institution who studies the Middle East, said Hamas is known to have used hospital sites as well as schools to shield their activities from Israeli soldiers.

“Israel isn’t fighting in the hospitals because Hamas isn’t there,” he said. “But in the end, this is a matter of fact that will have to be proven.”

The fighting around hospitals is expected to endanger what little medical access that beleaguered Palestinians have left.

Humanitarian group Doctors Without Borders shared testimony from a witness at Al-Shifa, where there are no basic necessities, ambulances have allegedly fallen under crossfire and people have died after losing access to ventilators.

Some hospitals have already shut down in Gaza after running out of fuel, and fears are mounting that more will run out because of Israel’s blockade on the coastal enclave. The Palestine Red Crescent Society, a humanitarian group, said Tuesday it managed to evacuate all patients and staff out of the al-Quds hospital.

Zivot, of the Emory School of Medicine and who is also a physician working in intensive care units, suggested evacuating patients to nearby hospitals in Israel, Jordan or Egypt, even as he acknowledged it was difficult to carry out those operations quickly.

“If a hospital isn’t functioning or lacks the capacity to provide a service, then you evacuate that person,” he said. “It becomes the responsibility of the international community to help … Qatar, the [United Arab Emirates], Saudi Arabia [should] come forward and help these people evacuate and put them in your hospitals.”