Israel's violent week-long February ground incursion into Nasser Hospital, the largest in southern Gaza, seems just a blip in the long litany of assaults that have killed more than 30,000 Palestinians and left almost the entire population of 2.3 million bereft of shelter, safety and basic order, food, clean water, and essential medical care.
Yet that attack continued Israel's relentless destruction of Gaza's already reeling health system, and provided a graphic, set piece microcosm of Israel's flagrant disregard of the oldest duty contained in the Geneva Conventions, dating to 1864, to respect and protect the wounded and sick.
The raid and its grim aftermath reinforce the urgent need for President Joe Biden's administration to hold Israel accountable for its conduct—beyond its increasingly critical statements, including President Biden's blunt (and laudable) declaration, in his March 7 State of the Union Address, that the ongoing war "has taken a greater toll on innocent civilians than all previous wars in Gaza combined."
Regardless of the outcome of ceasefire negotiations, the Biden administration should hold Israel to account for its conduct of the war and the obstruction of passage of humanitarian aid by reporting on war crimes committed by all parties, announcing support for International Criminal Court (ICC) investigations, ending arms transfers to Israel that are used to breach international law, and resuming funding of the United Nations Relief and Works Agency for Palestinians (UNRWA) to meet the humanitarian crisis.
So too, the raid reinforces the urgency of the administration taking a stand against the Israeli campaign to undermine and delegitimize UN agencies and nongovernmental health and humanitarian agencies, both Palestinian and international, that struggle to alleviate the worsening human catastrophe in Gaza.
Israeli Narratives
On February 15, after a week-long siege and shelling of Nasser Hospital, Israeli ground troops forced thousands of displaced people sheltering in the large compound to abruptly leave while the Israel Defense Forces (IDF) assaulted the facility. As in prior hospital incursions, Israeli spokespeople claimed that Hamas used the hospital for military operations and to hold the bodies of two Israeli hostages, both of which could be war crimes.
As the assault began, Israel repeated a now-familiar mantra, that it would "ensure that the Nasser Hospital continues its important function of treating Gazan patients." Shortly after the incursion, the IDF touted that it coordinated supply of oxygen tanks, food, water, a fuel tank, a generator, medical equipment, and baby formula in conjunction with international actors.
This Israeli narrative of concern for the patients and medical staff continued throughout the week-long incursion. On February 18, Coordination of Government Activities in the Territories (COGAT), the Israeli agency that implements civilian policies in Gaza, said that the operation was "conducted with careful management of the hospital, ensuring no harm to patients and medical staff, in accordance with IDF values and international law."
After the troops left, the narrative continued. In addition to claiming that the operation was a success, having found weapons and detained 200 "terror suspects," Israel assured the world that the operation was "conducted with careful management of the hospital, ensuring no harm to patients and medical staff" and said that the incursion "was done to ensure minimal disruption to the hospital's ongoing activities." It fixed a generator and said that the soldiers cleaned the area before they left.
As in prior assaults on hospitals in Gaza, Israel's account omitted essential facts and misrepresented circumstances on the ground—part of a systematic, sweeping pattern of obfuscation and unsubstantiated allegations, including claims of complicity with Hamas, directed at UN agencies and NGOs. For two days after the incursion began, the IDF denied a team from the World Health Organization (WHO) access to the hospital to assess patients and arrange evacuation of the most serious cases. In the first attempt, the WHO team was allowed into the compound but not the hospital and was forbidden from speaking to the hospital director about patients who needed urgent evacuation. Those included profoundly sick and injured people—with medical issues from paralysis to tracheostomies, spinal fractures, and external fixations for orthopedic injuries—who could no longer be treated in what had become an utterly anarchic situation.
[Palestinians] didn't believe they would make it
Rik Peeperkorn, WHO representative
When, on the third day, the WHO was finally allowed entry, it reported that the hospital had no electricity or running water, and "medical waste and garbage are creating a breeding ground for disease." The intensive care unit was not functioning. The WHO also learned that shortly after the assault began, electricity ceased and at least five patients in need of oxygen died.
Rik Peeperkorn, WHO representative in the occupied Palestinian territories, observed that the medical staff were desperate, struggling to cope without food, water, electricity, and supplies. He said, "they didn't believe they would make it."
The WHO and Palestinian Red Crescent arranged the medically delicate and highly dangerous evacuation of 31 patients at greatest risk of death. Subsequent medical evacuations raised the number of patients removed from the hospital to 51. During the raid, as in past hospital incursions, the IDF detained members of the medical and support staff, in this instance 70 people.
Three detained staff independently told the BBC that they had been blindfolded, humiliated, beaten with sticks, hoses, rifle butts and fists, forced to kneel in uncomfortable positions, and doused with cold water by IDF soldiers. The troops broke the hand of one person, and some patients had their hands zip-tied. The IDF said that the medics were detained for interrogation, acknowledged that some patients were zip-tied, and declared that it treats detainees well. Some of the detained medics have not returned and families have no information about them.
When the troops left, only a handful of staff remained to care for the estimated 130 sick and injured patients inside the severely damaged hospital. They were forced to move seriously ill patients and work in cramped and unsanitary conditions. When the siege ended, the WHO reported that the hospital had become utterly nonfunctional. A surgeon described the emergency department as a "death zone."
What International Law Requires
Hospital incursions in war are permitted under international humanitarian law when combatants use a health facility for military purposes and a warning has been given. But in doing so, the duty to respect and protect the wounded and sick and their caregivers remains. Combatants must ensure that the patients receive care to the fullest extent practicable and with the least possible delay, as required by their condition, and that health personnel be allowed to do their jobs. The definitive International Committee of the Red Cross (ICRC)'s Commentaries to the Geneva Conventions and Protocols make clear that when a hospital is legitimately attacked for misuse, entering troops must prevent "wounded and sick who are hospitalized in the unit from becoming the innocent victims of acts for which they are not responsible." It adds that "it is of paramount importance that the fate of the legitimate occupants of the medical unit is guaranteed."
The ICRC, in consultation with more than 27 militaries, has published practical guidance ("Protecting Healthcare" and "Promoting Military Operational Practice") on how to carry out this duty. It advises coordinating entry with the medical staff in the facility to ensure patient care and to minimize the disruption and instructing troops not to enter neonatal and intensive care wards. Other militaries have taken steps to protect patients in hospital searches. In Afghanistan, coalition headquarters issued an order requiring approval of hospitals entries by a two-star general, severely restricting how hospital searches are conducted.
Troops must prevent wounded and sick who are hospitalized in the unit from becoming the innocent victims of acts for which they are not responsible
Some defenders of the IDF's conduct have claimed that Israel is doing only what the U.S. military does, citing the occupation of Iraq's Fallujah Hospital in 2004. In that case, although the hospital entry was violent, within an hour, doctors were back to attending to the most seriously ill patients, none of whom suffered.
In Gaza, Israel has chosen to abandon obligations to save patients before and during hospital assaults. It repeats the false and misleading mantra that it makes "extraordinary efforts" to avoid civilian casualties and supports hospital functioning. At the same time, it consistently denigrates UN agencies—including the WHO and the UNRWA, as well as the UN Secretary General—along with the ICRC and the Palestinian Red Crescent Society. These humanitarian groups and others are struggling, in the worst possible circumstances, to save lives. Eylon Levy, a spokesperson for the Israeli government, said—falsely—that, during the incursion into Nasser Hospital, the IDF facilitated supply of medications to the hospital donated by the WHO despite the WHO's "continued cover-up of Hamas's abuse of the hospital."
Avril Benoit, executive director of Doctors Without Borders (Médecins Sans Frontières in the United States) explained that "there's a whole machine that is looking to pick apart and cut down independent humanitarian action—principled humanitarian action that is trying to reach the most vulnerable." Despite widespread global revulsion at Israel's conduct, Israel's campaign has nonetheless gained traction in the United States. It is not only by uncritical supporters of Israel but by otherwise sober and skeptical editorial writers. The campaign is aided by the exclusion of independent foreign journalists from Gaza, and the reported deaths of almost 100 journalists there, more than 90% of them Palestinians.
These deflections cannot be allowed to obscure the now long catalog of Israeli—as well as Hamas—actions in Gaza that could constitute crimes.
Where the United States Can Intervene
The United States has a mixed record of support for accountability for war crimes but can play an effective role when engaged. It has not joined the ICC but is now sharing evidence with the prosecutor regarding Russian crimes in Ukraine. The State Department has reviewed and reported on war crimes committed by parties to the ongoing conflict in Sudan and imposed sanctions. But thus far it has deflected questions on Israel's breaches of international law, as recently as January, saying that it has no indication of Israeli commission of war crimes.
In February, the State Department announced that it was reviewing incidents in the war under a new civilian harm mitigation program applicable to both U.S. and allied forces. But the review is designed to address policy options that could reduce risks of harm in the future. It is not an investigation of war crimes and crimes against humanity.
There is much the Biden administration should do. As Israel's foremost political and military supporter, the United States has an obligation to review and speak to the claims of war crimes, in connection with use of arms it provides to Israel, including more than 100 arms sales to Israel since Hamas massacred more than 1,200 Israelis and took 240 hostages on October 7. It should expedite reviews of the Israeli use of U.S. weapons that may fall well under U.S. arms transfer law, the commitment to which was recently reaffirmed in an executive order. It should also conduct and publish a review of potential crimes by all parties in the conflict unrelated to arms sales, including whether Israel has breached obligations to the wounded and sick or engaged in intentional starvation of a population, including willfully impeding relief supplies, which is a war crime.
The Biden administration should follow the lead of Chile and Mexico and offer intelligence support for ICC investigations of crimes committed by all sides in the war. The United States can meanwhile conduct its own internal review of war crimes and crimes against humanity.
Another crucial action for the Biden administration would be to demand openly that Israel cease malicious accusations against UN agencies and Palestinian and international NGOs that put themselves at enormous risk in trying to address the calamity in Gaza.
These proposed steps are clearly in the U.S. national interest. They will build accountability by the IDF for the weapons the United States supplies and avoid U.S. complicity in future potential crimes. They will signal to Israel that it is to face consequences in its relationship with the United States for its reckless conduct and false statements about it. And they will complement and reinforce the extreme urgency of the United States moving forward resolutely on the rapidly worsening human crisis in Gaza.
As Israel's foremost political and military supporter, the United States has an obligation to review and speak to the claims of war crimes
In the first five months of the Hamas-Israeli war, according to Palestinian health authorities, more than 30,000 people have been killed and more than 70,000 have been seriously wounded. These numbers equate to more than 4% of the total population and are likely a serious undercount. Worsening malnutrition, most severe in northern Gaza but perilous throughout, places Gaza on the edge of galloping famine and starvation, and continued warfare, including a possible siege of Rafah, will rapidly push the numbers of dead and wounded to much higher levels. Events are on course for a doubling.
The United States and other allies (the European Union, Jordan, the United Arab Emirates, and the United Kingdom), in exasperation over Israeli intransigence, in the face of Gaza's worsening human crisis, have recently chosen to initiate air drops and the establishment of a maritime relief corridor between Cyprus and the Gaza coast that will feature the construction of a floating pier by the U.S. military.
These desperate measures could eventually, in the coming months, achieve some scale. For now, though, they have drawn much skepticism, indeed, harsh criticism. They do not speak to or alter the need for Israel to unblock access, a political decision. Air and sea deliveries are no substitution for land deliveries. Sea and land deliveries in the near term are a delusion and distraction. It remains altogether unclear how assistance delivered by air and sea will reach those in greatest dire need, who will be the on-the-ground partners; what level of relief will be truly possible; and how and why these deliveries will be any more successful than those by land in overcoming Israeli obstruction and operating amid northern Gaza's devastation and anarchy. Most immediately significant, air and sea deliveries will not change the steady escalation of excess mortality and obscene levels of avoidable suffering.
Continued Israeli false accusations against and denunciation of UN agencies and NGOs will severely impede their ability safely to organize and transport food and other necessities. The Biden administration must demand that Israel cease. It must also resume funding of UNRWA, which is essential to the humanitarian response, while legitimate investigations proceed.
Only with such U.S. leadership and a fundamental change of course will there be genuine hope of reversing the tragic trajectory seen in Gaza.
