© 2025 Palestine Center for Public Policy
The destruction of Gaza’s healthcare system represents one of the most serious legal and institutional failures in the contemporary international order. Despite binding obligations under the Geneva Conventions, the International Health Regulations (IHR), and international human rights law, attacks on hospitals, medical personnel, and humanitarian agencies have continued without meaningful accountability. The institutions responsible for enforcing these protections, including the United Nations Security Council, the International Criminal Court (ICC), and the World Health Organization (WHO), have proven unable or unwilling to respond. In most instances this inaction has resulted from political obstruction or structural limitations in their mandates.
This brief examines the conditions that enabled this failure and outlines legal and institutional reforms to reestablish credibility in the enforcement of humanitarian norms. It focuses on three areas.
The implications extend far beyond Gaza. If legal protections are not enforced in this context where violations are sustained, well documented, and in clear breach of international norms, then the legal framework for protecting civilians during war risks becoming irrelevant. Inaction does not preserve neutrality. It undermines the rule of law and signals that the right to health can be disregarded in armed conflict. Without structural reform, this failure will not remain an exception. It will become precedent.
Gaza’s health system has not deteriorated through neglect. It has been deliberately dismantled through prolonged military operations, access restrictions, and sustained attacks on medical infrastructure. Hospitals have been reduced to rubble. Ambulances have been targeted. Surgeons have been detained or killed. Patients, including children, have undergone surgery without anesthesia.
According to an analysis published in The Lancet, the death toll in Gaza may exceed 186,000. This estimate accounts for both direct and indirect deaths, including those caused by starvation, untreated illness, and the collapse of essential healthcare. The methodology, while not officially adopted by all states, is peer reviewed and based on precedent from other high-casualty conflicts.
Before October 2023, Gaza operated 36 hospitals serving a population of over 2.2 million. As of early 2025, only 18 remain partially operational. Most function without electricity, clean water, sterilization, or basic surgical supplies. Vaccination campaigns have ceased. Pregnant women give birth in makeshift shelters. Children with injuries are denied basic care. The territory’s primary healthcare provider, the United Nations Relief and Works Agency (UNRWA), has been repeatedly targeted, and more than 160 of its staff have been killed.
These outcomes are not the result of legal uncertainty. Under the Geneva Conventions, the IHR, and the Rome Statute of the ICC, the protection of healthcare systems and civilian access to medical care during armed conflict is a clear legal obligation. Yet in Gaza these obligations have been ignored. Existing enforcement mechanisms have failed to operate. Institutional paralysis, political obstruction, and selective application of the law have left these protections without consequence.
This brief analyzes the structural conditions that have enabled legal protections to fail in practice. It does not focus on the theoretical scope of international law, but on its collapse under political pressure and institutional paralysis. Drawing on established legal frameworks and recent proceedings at the ICC and ICJ, the brief examines how enforcement gaps have allowed the systematic destruction of Gaza’s health system to proceed without consequence. It concludes with targeted legal and institutional reforms that aim to restore the credibility and operational force of humanitarian law in conflict.
What is happening in Gaza is not an isolated failure. It is a global warning. If civilian protections collapse here, they will not hold anywhere.
Since October 2023, Gaza’s healthcare system has experienced sustained and deliberate destruction. Prior to the escalation, 36 hospitals served a population of over 2.2 million. As of early 2025, only 18 remain partially operational. These facilities lack electricity, clean water, anesthesia, sterilization equipment, and essential supplies. Many are surrounded by rubble. Medical evacuations have been blocked. Ambulances have been struck while in service. Patients with traumatic injuries wait without treatment. Vaccination programs have collapsed. Women deliver in overcrowded shelters under unsafe conditions.
Several hospitals have come under direct attack. Al-Ahli Hospital was struck by an explosive device while civilians were sheltering in the courtyard. Investigations by Human Rights Watch and Forensic Architecture concluded that the weapon used was consistent with Israeli munitions. At Al-Shifa Hospital, Gaza’s largest, Israeli forces conducted a military operation that trapped patients and staff for days without basic care. Israeli authorities alleged the site was used for military purposes, but no independent investigation has verified these claims or established lawful grounds for revoking protected status under international law.
The toll on healthcare personnel has been catastrophic. More than 600 doctors, nurses, and paramedics have been killed. Medical staff have been detained, stripped, and beaten. Gaza’s most senior orthopedic surgeon, Dr. Adnan al-Bursh, was arrested during a raid. He was reportedly assaulted in Israeli custody and later died. Pediatrician Dr. Muhammad Abu Safiya remains detained without charge. No legal proceedings have been disclosed in his case.
Children in Gaza have suffered severe physical and psychological harm. The territory now has the highest number of child amputees per capita in the world. More than 90 percent of children show symptoms of trauma. In one widely documented case, six-year-old Hind Rajab made an emergency call while trapped inside a vehicle surrounded by the bodies of her family. Paramedics dispatched to find her were later found dead in destroyed ambulances.
UNRWA, Gaza’s primary healthcare provider, has also been repeatedly targeted. Over 160 of its staff have been killed. More than 100 UNRWA facilities, including schools and clinics bearing UN insignia, have been damaged or destroyed. UNRWA has publicly described these attacks as part of a systematic campaign to dismantle humanitarian services. Despite repeated requests, no protective mechanisms have been enforced.
These events are not unverified claims. They are documented by international organizations, medical associations, and independent human rights monitors. The cumulative effect is not a strained system. It is the collapse of civilian medical care for an entire population. Gaza’s healthcare infrastructure was not overwhelmed by internal capacity or mismanagement. It has been taken apart under siege, while legal protections remained in place but unenforced.
The destruction of healthcare infrastructure in Gaza and the obstruction of medical services are not legal gray areas. The protection of civilian health systems during armed conflict is a core obligation under international law. It is codified in multiple binding treaties and affirmed by state practice, judicial precedent, and customary norms.
Two bodies of law govern health protections during conflict. International Humanitarian Law (IHL), also known as the law of armed conflict, regulates the conduct of hostilities. It prohibits targeting civilians and civilian infrastructure, including hospitals and ambulances, and requires the protection of medical personnel and humanitarian actors. International Human Rights Law (IHRL) governs the rights of individuals in all contexts, including during conflict. Together, these frameworks impose overlapping and complementary obligations. IHL governs the means and methods of warfare, while IHRL guarantees rights such as access to healthcare, nondiscrimination, and due process.
The Fourth Geneva Convention of 1949 prohibits collective punishment and requires occupying powers to ensure access to medical care and public health. Article 56 mandates the maintenance of medical services and hygiene in occupied territories. These obligations are triggered not by the presence of ground troops but by effective control. The International Court of Justice (ICJ) affirmed this standard in its 2004 advisory opinion on the construction of the wall in the occupied Palestinian territories. The Court found that both IHL and IHRL apply extraterritorially wherever a state exercises control over a population.
The IHR, adopted by the World Health Assembly and binding on all member states including Israel, require the preservation of essential public health functions during crises. Although originally developed to manage cross-border disease threats, the Regulations impose a global duty to prevent health system collapse and to ensure access to care during emergencies. These obligations are not suspended during armed conflict.
Under IHRL, the right to health is guaranteed in Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR). This includes the obligation to prevent, treat, and control disease and to provide access to medical services without discrimination. The Convention on the Rights of the Child reinforces these protections. It requires states to ensure access to health services for children and to protect them from the effects of hostilities. These treaties remain fully applicable in armed conflict.
Customary international humanitarian law also affirms these norms. The International Committee of the Red Cross has identified rules that apply in all conflicts. Rule 25 requires the protection of medical personnel at all times. Rule 28 prohibits attacks on medical units and transports. These rules are binding regardless of the political context or legal status of the parties involved.
The Rome Statute of the ICC criminalizes the intentional targeting of hospitals, medical personnel, and humanitarian actors, as well as the denial of humanitarian assistance. Where such acts are widespread or systematic, they may constitute war crimes or crimes against humanity. In 2024, the ICC issued arrest warrants related to the situation in Gaza, confirming that these provisions are not dormant but enforceable.
These obligations are further reinforced by treaty law. Article 26 of the Vienna Convention on the Law of Treaties requires that all treaties be performed in good faith. Article 31 requires that they be interpreted in light of their object and purpose. In the case of humanitarian and health-related treaties, that purpose is the protection of civilian life and dignity.
The legal framework is not contested. It has been ratified, codified, and reaffirmed across jurisdictions and institutions. What remains missing is enforcement.
Although the legal obligations protecting healthcare systems during armed conflict are well established, enforcement has failed in the case of Gaza. This is not a failure of legal clarity. It is the result of structural limitations, political obstruction, and the unwillingness of key actors to apply the law impartially.
The United Nations Security Council, mandated to maintain international peace and security, has been unable to adopt binding measures to protect healthcare in Gaza. Repeated vetoes by permanent members, especially the United States, have blocked resolutions calling for ceasefires, humanitarian access, and independent investigations. As a result, the Council has remained inoperative while health infrastructure is destroyed and medical personnel are killed.
When the Security Council fails to act, responsibility shifts to other institutions. Yet both the WHO and the ICC have been restricted in their ability to respond.
The WHO, although authorized under the IHR to coordinate global public health emergencies, lacks the authority to compel state compliance. In Gaza, its access has been limited by Israeli-imposed restrictions on movement, aid delivery, and field operations. WHO has issued warnings and appealed for protection of healthcare facilities, but without enforcement powers or unrestricted access, its role has been limited to public advocacy.
The ICC has jurisdiction over war crimes and crimes against humanity in the occupied Palestinian territory, following Palestine’s accession to the Rome Statute. In 2024, the Court issued arrest warrants related to attacks on civilians and the denial of humanitarian aid. Israeli officials rejected the Court’s jurisdiction, arguing that Palestine is not a state. These arguments have been dismissed by the Court. In response, the United States imposed sanctions on the Prosecutor, further undermining the Court’s independence and deterring future action.
UNRWA, which provides primary care to approximately 70 percent of Gaza’s population, has also come under sustained political pressure. Following allegations by Israeli authorities that some staff were affiliated with armed groups, several donor states suspended funding. A UN-commissioned independent review, led by former French Foreign Minister Catherine Colonna, concluded in April 2024 that there was no systemic basis to dismantle the agency. From April 28 to May 2, 2025, the ICJ held hearings in response to a request from the General Assembly for an advisory opinion on Israel’s obligations concerning humanitarian aid. The proceedings examined the legality of restrictions on UNRWA operations. Multiple states, including the United Kingdom, reaffirmed that Israel remains legally obligated to allow humanitarian access and to respect the neutrality of United Nations agencies. The Court has not yet issued its opinion, but the hearings made clear that these restrictions raise serious legal concerns.
Israel has also claimed that it is no longer bound by the obligations of occupation, citing its withdrawal of ground forces from Gaza in 2005. However, authoritative bodies including the United Nations, the ICJ, and the International Committee of the Red Cross maintain that Israel remains the occupying power due to its control over Gaza’s borders, airspace, and access to essential goods and services. Under the Fourth Geneva Convention, that control carries legal responsibilities, including the duty to ensure medical care and public health.
Israeli authorities have further alleged that some hospitals and ambulances have been used for military purposes. International humanitarian law does allow for limited exceptions in cases of confirmed misuse, but only where there is credible, independent evidence and where the principles of necessity and proportionality are met. No such process has been demonstrated in Gaza. Independent monitors, including United Nations agencies and international human rights organizations, have found no sufficient basis for revoking the protected status of healthcare facilities.
Enforcement failure is not confined to international institutions. Third-party states have also failed to discharge their legal responsibilities. The United States continues to provide military and financial assistance to Israel despite credible allegations of serious violations of international humanitarian law. Domestic laws such as the Foreign Assistance Act and the Leahy Laws require suspension of assistance in cases involving gross human rights violations. These statutes have not been enforced.
Other states have similarly failed to act. In its 1971 advisory opinion on Namibia, the International Court of Justice held that states have an obligation not to recognize or assist in the maintenance of unlawful situations. In Gaza, several governments continue to provide diplomatic and material support despite their legal obligations to intervene or withhold cooperation.
The result is a system in which the enforcement of legal protections depends on political alignment. Laws that are universally ratified are selectively applied. Institutions tasked with upholding civilian protections have been rendered ineffective, not because they lack legal authority, but because the political will to activate that authority has been absent.
The failure to enforce protections for healthcare in Gaza is not limited to one territory or one conflict. It reveals a broader collapse in the enforcement architecture of international law. If hospitals can be destroyed, medical personnel targeted, and humanitarian operations obstructed without consequences, then the legal framework designed to protect civilians in armed conflict loses its force. It becomes rhetorical rather than operational.
Treaties such as the Geneva Conventions, the IHR, and the Rome Statute derive their legitimacy from implementation. If states and institutions fail to uphold them in a context where violations are sustained, documented, and legally unambiguous, the norms they establish will begin to erode. This will not be limited to Gaza. The precedent will inform the behavior of other actors, including armed groups and state militaries, who will see that international health protections are subject to political discretion rather than legal obligation.
The implications for global governance are serious. The United Nations Security Council has been paralyzed. The WHO has been obstructed from operating in one of the most severe health emergencies in recent history. The ICC has faced sanctions for attempting to fulfill its legal mandate. If these institutions cannot function where the law is clear and the humanitarian need is urgent, their credibility in other crises will be permanently weakened.
Selective enforcement also undermines the legitimacy of states that rely on international law to promote their interests. Governments that defend the legal order in one context while disregarding it in another weaken their own moral and strategic credibility. The same frameworks being bypassed in Gaza are the ones used to constrain adversaries, protect allies, and justify claims of principled leadership. Legal norms cannot be applied selectively without damaging the entire system.
For the United States and other influential states, the long-term cost of inaction is institutional as well as reputational. The failure to apply existing domestic laws such as the Foreign Assistance Act and the Leahy Laws in this case undermines their future use. If these statutes are not enforced when violations are clear, they risk becoming politically symbolic rather than legally binding.
What is unfolding in Gaza is not only a humanitarian emergency. It is a test of whether the international legal system can function under political pressure. If this failure is allowed to stand, it will not remain an exception. It will become the model.
The failure to protect healthcare systems during armed conflict requires structural reform. The legal framework exists, but enforcement depends on institutional coordination, political will, and the operationalization of existing obligations. The following recommendations are legally feasible, procedurally grounded, and institutionally actionable.
1. Amend the International Health Regulations to include conflict-related health system collapse
The IHR, adopted by the WHO and binding on all member states, currently address cross-border public health emergencies such as disease outbreaks. They do not address the collapse of healthcare systems caused by war. The World Health Assembly should adopt a protocol or annex defining conflict-related health system collapse as a public health emergency of international concern. This would trigger international reporting, coordination, and mobilization. The infrastructure to support such measures already exists within the World Health Organization, including emergency surveillance and response capacities.
2. Establish a formal protocol between the World Health Organization and the International Criminal Court
The ICC has jurisdiction over war crimes involving attacks on hospitals, medical personnel, and humanitarian operations. The WHO is often the only public health actor present in conflict zones. A formal cooperation protocol should allow for the transfer of verified health-related data, including forensic epidemiology, damage assessments, and patterns of harm. This would not compromise the neutrality of the WHO, but would allow its data to support evidentiary records in legal proceedings before the ICC.
3. Invoke the Uniting for Peace mechanism when Security Council action is blocked
When the United Nations Security Council is unable to act due to the veto of a permanent member, General Assembly Resolution 377A authorizes the General Assembly to take emergency measures. In past conflicts, including the Suez War and the Soviet invasion of Afghanistan, this mechanism was used to initiate investigations and coordinate member-state responses. In Gaza, where the Security Council has failed to act, member states should invoke Resolution 377A to authorize humanitarian protections, establish independent inquiries, and facilitate enforcement by other United Nations bodies.
4. Enforce conditionality in military assistance and development cooperation
Many governments already maintain legal mechanisms that prohibit assistance when there is credible evidence of serious human rights violations. These include the Leahy Laws and the Foreign Assistance Act in the United States, the European Union Common Position on Arms Exports, and donor frameworks developed by the Organisation for Economic Co-operation and Development. These measures must be enforced consistently. Governments and donor institutions should establish independent review bodies, require public justification for waivers, and adopt automatic suspension provisions tied to objective findings of noncompliance.
5. Integrate harm-based enforcement clauses into contracts and financing agreements
United Nations agencies, multilateral development banks, and global health donors should incorporate clauses in grants, contracts, and procurement agreements that trigger consequences when healthcare infrastructure is damaged during conflict. These consequences could include legal review, funding suspension, or reputational sanctions. These mechanisms should not require attribution of intent. They should be based on defined thresholds of harm, verified by independent bodies such as the WHO or the United Nations Office for the Coordination of Humanitarian Affairs. This model reflects enforcement tools already used in environmental law and corporate due diligence frameworks.
6. Mandate an independent international inquiry into the destruction of Gaza’s healthcare system
An expert-led, time-bound commission should be established to investigate the legal, institutional, and operational failures that led to the collapse of Gaza’s health system. The mandate should include analysis of violations under international humanitarian law, international human rights law, and the IHR. It should also assess failures of coordination among United Nations agencies, donors, and humanitarian actors. The findings should be submitted to the ICC, inform reforms within the WHO, and serve as a model for post-conflict health accountability in future crises.
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