Europe Solidaire Sans Frontières
More than a month after the war in Gaza broke out, the fighting has one salient symbol: Al-Shifa Hospital in the western part of Gaza City. The combination of it being the largest, most important hospital in Gaza, a fast growing refugee camp for desperate Gazans of all ages, and a tool used by Hamas – as a vast human shield above the organization’s main command center – embodies the impossible challenge it presents for Israel.
Evidence accumulating since the war’s onset indicates that Al-Shifa has become the central headquarters for the Hamas leadership’s activity. In the past week the Israeli army has been laying the groundwork for justifying an attack on the medical center, by releasing almost daily evidence of the terror activity occurring beneath and around it, framing it as a war crime by Hamas.
Two weeks ago, IDF Spokesman Brig. Gen. Daniel Hagari issued a statement saying that beneath the hospital lies Hamas’ central command headquarters, from where Hamas directs the fighting against Israel and where it stores arms and ammunition. The army also revealed that entry to the underground command centers is through a number of tunnel shafts both close to the hospital and inside the hospital wards, including internal medicine, dialysis and outpatient clinics.
Officials in Israel don’t deny that Israel is considering the possibility of bombing Al-Shifa or attacking it by air, despite the presence of patients, staff, and tens of thousands of Gazans in the compound.
The army also announced that Hamas is using the hospital’s electricity supply for itself. The IDF Spokesman also publicized recordings from interrogations of terrorists, in which the terrorists describe how Hamas commanders and terrorists hide in hospitals and move people and equipment around in civilian ambulances because Hamas knows that Al-Shifa is a “safe place that won’t be bombed.”
Displaced Palestinian children, who fled their house due to Israeli strikes, sit in a makeshift shelter at Al-Shifa hospital, November 5, 2023.Credit: REUTERS/Mohammed Al-Masri
There was also a recording of a conversation with an official in the Gazan health system who admits that Hamas is keeping more than 500,000 liters of fuel underneath the hospital, and that hundreds of the terrorists who took part in the October 7 massacre and fled back into Gaza are hiding out in the hospital.
‘Old-fashioned hospital – with professional staff’
A surprising number of Israeli physicians are well-acquainted with Al-Shifa. Since 2009, a delegation of doctors from Physicians for Human Rights has been visiting Al-Shifa monthly and performing each time, together with Al-Shifa physicians, 30 to 50 surgeries, including orthopedic, thoracic, kidney and cardiac cases. The delegations to Gaza are comprised solely of Arab physicians, at the instruction of the army and the Shin Bet security service. The delegations visiting West Bank hospitals include Jewish doctors, too.
The monthly visits had a dual goal: assisting local medical staff with relatively complicated surgeries and with cases that could not be referred to hospitals in the West Bank or Egypt, and also training the Gazan doctors to perform the surgeries themselves, as if it were a residency. “For example, a senior transplant surgeon from Israel instructs the local staff and performs kidney transplants together with them. After a few rounds like this, the local doctor can perform the kidney transplant independently,” explained Salah Haj Yahya, director of PHR’s mobile clinic and medical delegations to Gaza and the West Bank.
On ordinary days, there used to be 540 doctors, of various nationalities, working at Al-Shifa, but Salah Haj Yahya said that no more than 200 doctors remain.
A satellite image shows Al-Shifa hospital, amid the ongoing conflict between Israel and the Palestinian Islamist group Hamas, in Gaza November 2023.Credit: Maxar Technologies/Handout via REUTERS
“Everything our doctors do is filmed on video in the operating rooms. And after 10, 15 surgeries, we watch the surgeries together for training purposes. There is also continuous daily contact. When the Palestinian doctors run into a tricky case, they contact us, and our doctors advise them on what to do with the patient.” The delegations also hold large medical conferences: “The conferences are organized according to what the doctors request – on subjects like hypertension, diabetes, gynecology,” Haj Yahya noted. “There are hundreds of participants.”
Bombing a hospital is an action that is considered extreme, and the goal must be very just and clear.
Dr. Idit Shafran Gittleman
A., a senior physician at an Israeli hospital who asked to remain anonymous, is a regular member of these delegations. He has been volunteering for a decade and goes to Al-Shifa and to the hospital in Khan Yunis. He said: “Compared to Israel, the hospital is a few generations behind, kind of like something from the 1970s. The surgery wing is new and has new operating rooms, but the maternity ward, for example, is quite outdated. It’s built as one big space, with just a sheet separating the women in labor.”
He added: “They used to bring a large percentage of the tough cases from Gaza to Israel, but over the years it shrank to about 10 percent. We built a special training program for the Gazan doctors. We were able to bring them new equipment, and we trained them in different surgeries.
The doctors at Al-Shifa are eager to learn new things but can’t go out, so they’d wait for us and ask us to come. Essentially, this was their residency. Some of them studied medicine abroad, mainly in Eastern Europe but also in countries like Turkey, Sudan, Pakistan and Yemen. My impression was that they are quite professional. I was even a bit surprised, because at first I thought that wouldn’t necessarily be the case.”
’We bring crucial equipment with us as part of the visits by the medical delegations to Al-Shifa, because otherwise we couldn’t do a single operation there. It is all done in coordination with the Israeli authorities.’
Open gallery view; Salah Haj Yahya, director of PHR’s mobile clinic and medical delegations to Gaza and the West Bank.Credit: Itay Ron
Haj Yahya said that the medical activity, and particularly the surgical activity, at Al-Shifa relies in large part on donations. “The hospital and the operating rooms are missing basic things, so you have to adapt the surgery to what they have and not vice-versa,” he said. “We bring crucial equipment with us as part of the visits by the medical delegations to Al-Shifa, because otherwise we couldn’t do a single operation there. It is all done in coordination with the Israeli authorities.”
A huge refugee camp
Al-Shifa is a large hospital. Above ground, it stretches across dozens of acres. Currently, it is much more than a hospital, having also become a huge refugee camp. Since the war began, tens of thousands of Palestinians have fled to Al-Shifa to find shelter from Israeli strikes in northern Gaza, believing that the army wouldn’t attack the hospital.
Reuters reported last week that refugees have filled the hospital grounds and are staying in makeshift tents in the waiting rooms and hallways. Hundreds of men were filmed last week sitting in the hospital yard, watching videos of the Hamas attacks and cheering. Two days later, the military detonated illuminating shells above and near the hospital, apparently in an attempt to signal to the masses there to leave.
This isn’t Al-Shifa’s first time at the center of fighting in Gaza. In January 2009, during Operation Cast Lead, the Shin Bet accused Hamas of taking over the hospital and hiding its men in the building, on the assumption that Israel wouldn’t dare strike the hospital (which it didn’t do). In July 2014, too, during Operation Protective Edge, top Hamas commanders were reportedly hiding there. In the present war, one of the most difficult in Israel’s history, the hospital plays a more central role than ever.
Open gallery view. Palestinian medics take a break after carrying wounded people into Gaza City’s Shifa hospital, during the 2014 Gaza War, also known as Operation Protective Edge.Credit: AP Photo/Lefteris Pitarakis
Al-Shifa is owned and operated by the Palestinian Health Ministry. It was built during the British Mandate period. When Egypt conquered the Gaza Strip in 1948, Al-Shifa became Gaza’s main medical center. Since Israel took control of Gaza in 1967, Al-Shifa has seen improvements. In the mid-1980s, Israel spent millions of shekels renovating Al-Shifa as a flagship, under the supervision of the Coordinator of Government Activity in the Territories. The aim was improving living conditions in Gaza.
“Al-Shifa is considered the largest hospital in Gaza, with a vast amount of space and over 500 beds (officially 1,500, according to the army). It provides 60 to 70 percent of all health services in Gaza, which has 35 hospitals, some of them tiny,” Haj Yahya said.
The hospital is made up of several wings – a surgical wing, an internal medicine wing and a maternity wing. It also has outpatient clinics, pathology, and an imaging department. The surgical wing includes 12 large operating rooms. “The hospital is considered the best and most advanced in Gaza Strip regarding size, doctors and departments. It has a good neo-natal unit, dialysis services. The main problem is the shortage of equipment and medicines, which impedes the staff from working,” says Haj Yahya.
On ordinary days, there used to be 540 doctors, of various nationalities, working at Al-Shifa, but Haj Yahya said that no more than 200 doctors remain, primarily caring for the many wounded arrivals. “The hospital has become one large trauma center,” said A. “Other treatments have decreased dramatically.”
Open gallery view. Newborns are placed in bed after being taken off incubators in Gaza’s Al-Shifa hospital after power outage, November 12, 2023.Credit: OBTAINED BY REUTERS
Open gallery view. Doctors from a delegation from Doctors Without Borders work side by side with Palestinian doctors at Al-Shifa, during the 2023 Israel-Gaza war.Credit: Doctors Without Borders
During our conversation, Haj Yahya called the hospital’s CEO. We asked him about the mood in the hospital. He replied: “There is a feeling of nationalism, belonging to Gaza, to our homeland. We are helping our citizens, treating the sick and wounded, and every day, during our treatment, we encounter wounded and dead relatives. There are many doctors here who have lost family members, and 126 of our staff members have been killed. Everybody who comes here will receive medical treatment, regardless of political affiliation.” In answer to our question, the CEO claimed that he wasn’t aware of any Hamas activity in the hospital. “We are a medical team and have no ties with Hamas,” he insisted.
Haj Yahya stated: “We’ve been working there for many years, and we never came across political or military administration. Even on the underground level, where imaging is done – we’ve seen only surgical rooms.
A. said: “I don’t want to imagine that the hospital could be bombed. I am really shocked by the idea and hope it doesn’t come to that.”
Open gallery view. Palestinians inspect the bodies of victims who were killed in Israeli bombardment as they lie outside Al-Shifa hospital in Gaza City on November 8, 2023.Credit: DAWOOD NEMER - AFP
‘Death sentence for the sick’
Officials in Israel don’t deny that Israel is considering the possibility of bombing Al-Shifa or attacking it by air, despite the presence of patients, staff, and tens of thousands of Gazans in the compound. On the contrary, IDF spokesperson Hagari himself made it clear regarding this possibility that “in this war, all options are on the table.”
Meanwhile, initiatives are being launched, with Israel’s permission, to establish field hospitals and hospital ships as alternatives to Al-Shifa and the other Gaza hospitals that have been turned into shelters for terrorists. In fact, Israel has requested this from some several European countries, so that these hospitals can take in the sick and wounded patients who’d be evacuated from Al-Shifa, including the transfer of premature babies in incubators and intubated patients. (Reuters reported Saturday night that Hagari said the military would help evacuate babies trapped in Al-Shifa on Sunday).
Last week, it was announced that the UAE was already establishing a 150-bed field hospital in Gaza; Italy will send a “floating hospital” off the coast of Gaza and will also set up a field hospital in the region; Egypt is setting up several field hospitals; and France and Greece have also expressed readiness to send floating hospitals. German newspaper Der Spiegel reported that the ships are supposed to anchor in Egypt, from there they would collect the wounded, who’d be permitted to leave Gaza.
’Sometimes, a benefit on the battlefront can cause tremendous damage on the international front. We need to constantly try to balance them.’
Open gallery view
Dr. Idit Shafran Gittleman, a senior researcher at the Institute for National Security Studies at Tel Aviv University, and an expert in the ethics in war.Credit: Moti Milrod
However, even if there will be alternative hospitals prepared to take in the wounded and sick, doubts remain about patient transportation. Would Hamas allow the transfer? What would Israel do with the tens of thousands of civilians at the site?
“Bombing a hospital is an action that is considered extreme, and the goal must be very just and clear,” said Dr. Idit Shafran Gittleman, a senior researcher at the Institute for National Security Studies at Tel Aviv University, and an expert in the ethics in war. “This war is being fought on three fronts – the battlefront, the homefront, and the international front. The interests among the three don’t always align. Sometimes, a benefit on the battlefront can cause tremendous damage on the international front. We need to constantly try to balance them.”
Still, the Geneva Accords explicitly establish that the humanitarian immunity afforded to hospitals in war will cease, with certain caveats,if they are being used to carry out acts of war. In other words, Hamas’ use of the hospitals would be a war crime.
“It is clear that using human shields in war is forbidden, but there is no clear answer as to what a state is actually permitted to do when the other side is using human shields,” Shafran Gittleman said. “On the one hand, the innocence of the non-combatants remains; on the other hand, the enemy’s tactics influence how we approach the proportionality issue.
"Two of the rules that apply throughout are the principle of distinction, which states that you may never directly target uninvolved civilians, and the principle of proportionality regarding harm to non-combatants as collateral damage in the course of a military operation. Direct harm is always prohibited, and indirect harm is allowed only insofar as it is subject to the rule of proportionality.”
How do you determine what is proportional in war?
“It is absolutely clear that any calculation of proportionality today is different from what it was before October 7, but not because of what happened – because revenge isn’t a legitimate action plan. Rather, it’s because proportionality anticipates future developments, what I want to prevent. Since we saw on October 7 that what we want to prevent is so murderous, the proportionality calculation changes.
"That’s why the IDF has stopped, for example, using the technique of ‘roof knocking’ (a procedure in which security forces would warn civilians before an air strike. R.L.), but still calls on people to evacuate to the southern Gaza Strip. And, of course, it doesn’t directly and intentionally fire at non-combatant civilians. But proportionality relates to an equation of the military objective relative to the harm to innocents, and there’s no definitive value for each of the parameters. You have to ask what the military value is, and what it advances, relative to the cost, and also, what the alternatives are.”
The feeling is that Hamas found the method for tying Israel’s hands – hiding behind innocent people.
“It’s difficult to act as a democratic state committed to the rule of law and to international law, but we don’t want to be like the terrorist organization we’re fighting against. Morality is very important for us, too, because on the day after, we’ll have to live with the consequences.”
Open gallery view. Injured Palestinians arrive at al-Shifa hospital in Gaza City, during the 2014 Gaza War, also known as Operation Protective Edge.Credit: AFP PHOTO / THOMAS COEX
Meanwhile, the issue has stirred up Israel’s medical community, following a letter signed by over 90 doctors, titled “Doctors for the Rights of IDF soldiers.” It seeks to be a counterweight to “Physicians for Human Rights.” In this letter, the doctors call “to destroy the hospitals serving as cover for terrorists” and claim that “the Gazan residents, who saw fit to turn hospitals into terror nests to take advantage of Western morality, are the ones who brought their destruction upon themselves.”
The letter, which calls for the destruction of the hospital with its occupants, led to a sharp response from various medical organizations. “The doctors swore to heal, not to kill,” wrote Dr. Tami Karni, chairperson of the Israel Medical Association’s ethics board. “Preserving morality has distinguished Israel throughout history. Israel’s doctors haven’t agreed to be dragged down into the enemy’s deterioriation of conscience and morality, and this is how we’ll continue to act.”
Similarly, the White Coats organization, which represents about 5,000 doctors and 2,000 health professionals, called the letter, “a proclamation by an extremist minority.” Within the organization, they say that calling for indiscriminate destruction and killing, even if they could be justified militarily, is not part of the medical ethical code.
Physicians for Human Rights issued a letter signed by 350 doctors and health and medical professionals, condemning the doctors’ call for Al-Shifa’s destruction. It stated: “Minimally, international law requires, beyond a warning, implementing precautionary measures to reduce civilian casualties relative to the perceived threat posed by the hospital. What guilt does a premature baby in an incubator bear, or someone whose legs were amputated in the bombing of his home during war, that they deserve to be annihilated?
They also rejected the legitimacy of the statements urging evacuating Al-Shifa patients elsewhere, “There is no hospital in Gaza that can take them in, and there are no ambulances to transport patients with complex cases, no incubators for premature babies, or doctors to accompany them,” the NGO argued. “Without all of these, the call for evacuation is not a humanitarian consideration. We must remove the veil from this deception; it is what it is: a death sentence for the sick.”
Ronny Linder
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