Al-Shifa Hospital siege

Al-Shifa Hospital, the largest medical complex in Gaza, was placed under siege by Israel in mid-November 2023 during the 2023 Israel–Hamas war, after claiming it had contained a Hamas command and control center beneath it.

On 11 November, the hospital was completely encircled, cutting it off from the rest of Gaza City, which contained 1,500 patients, along with 1,500 medical workers and some 15,000 displaced people seeking shelter in the hospital according to Gazan health officials. Israel and the United States alleged that below the hospital Hamas maintained command centers. Both the hospital's administration and Hamas denied that, the former asked the international community to send security experts to verify the Israeli allegations.

On 15 November, Israeli forces entered the hospital, with the Israeli military claiming it had discovered a Hamas command centre. BBC News and CNN reported that the Israeli army had rearranged, or even added, weapons for the media tour; and that an Israeli video showing the alleged discoveries had been edited. NBC News said that Israel released several pieces of inaccurate or disputed information, which weakened Israel's credibility. According to Al Jazeera, Israel was accused of fabricating evidence. On 22 November, Israel published video showing multiple tunnels beneath the hospital; the Wall Street Journal and the Guardian reported that this fell short of the original command center claims. Israel published surveillance footage taken by the hospital's cameras, appearing to show two hostages being taken into the hospital. The Guardian reported that Hamas had previously publicized taking hostages to receive medical treatment. On 21 December, the Washington Post published analysis concluding that the hospital buildings in question were not actually connected to the tunnels. On 2 January 2024, the United States released newly declassified documents showing that its spy agencies continued to believe that the hospital had been used as a command and control centre, and the following day Israel announced that it had dismantled a tunnel beneath the hospital. However, news reports the next day said that that both Israeli and US statements are not considered as conclusive proof of Hamas use of al-Shifa.

The raid on the hospital and Israel's limited findings of military infrastructure led to international criticism, including by UN High Commissioner for Human Rights Volker Türk who called for an independent investigation. International law prohibits the targeting of hospitals unless used for a military purpose that is "harmful to the enemy", as well as the use of human shields for combatants; both constitute war crimes. Israel has been accused of waging a propaganda war to detract from accusations that its actions at al-Shifa constitute violations of international law, and medical staff at al-Shifa have accused Israel of directly causing the deaths of civilians being treated at al-Shifa, including prematurely born babies. The head of the World Health Organization said, "hospitals are not battlegrounds," and that Israel's action was "totally unacceptable."

Background

Since 2007, the Gaza Strip has been under blockade by Israel and Egypt. On 7 October 2023, Hamas attacked Israeli civilian communities and military bases, killing around 1,200 Israelis, the majority of whom were civilians, and taking about 250 hostages into Gaza. Israel conducted a counterattack. Israel also imposed a total blockade on Gaza, invaded the Gaza Strip on 27 October, and surrounded Gaza City on 2 November.

Al-Shifa is the largest hospital in the Gaza Strip; it was originally a British army barracks but was converted into a hospital in 1946.

Hamas's presence in the hospital during the 2014 Gaza War is disputed. Israel has stated that the hospital was a Hamas control and command centre, and The Washington Post reported it had "become a de facto headquarters for Hamas leaders, who can be seen in the hallways and offices." By contrast, doctors Erik Fosse and Mads Gilbert, who were working at the hospital, stated that they did not see any evidence of military activity at the hospital during the war. Professor Sara Roy stated that military use of the hospital was "highly improbable". Amnesty International reported in 2015 that Hamas had used abandoned areas of the hospital to "detain, interrogate, torture and otherwise ill-treat suspects" while the hospital was operational.

The Israeli military had ordered all civilians in the region to evacuate on 13 October. The IDF reported that Hamas was preventing the evacuation of civilians from the area and particularly from Al Shifa hospital, with the IDF stating that Hamas was using civilians as human shields.

The IDF again requested all civilians in Northern Gaza and specifically Al-Shifa hospital to evacuate on 9 November. Thousands of displaced civilians were sheltering in the hospital at the time of the attacks on 11 November.

Legal status

Under the laws of war, hospitals normally enjoy protected status, making it forbidden to turn them into a conflict zone. However, that status is lost if there is evidence that the hospital is being used to make an "effective contribution to military action"; examples provided by Israel in its 2006 Rules of Warfare manual where a protected civilian structure loses its status include an anti-aircraft battery on the roof of a school, or a sniper in a mosque. According to the International Committee of the Red Cross (ICRC), this rule "has few exceptions". The exceptions include "carrying or using of individual light weapon in self-defense or defense of wounded and sick; armed guarding of a medical facility; or the presence in a medical facility of sick or wounded combatants no longer taking part in hostilities", which do not negate protected status as a medical facility.

According to Israel and the United States, conclusive evidence exists that Hamas used the building for military purposes; Hamas denies this. According to the ICRC, if there is doubt about whether a hospital is being used for military purposes, it should be presumed not to be being used militarily.

It does not negate protected status if a hospital has "small arms and ammunition taken from the wounded and sick and not yet handed to the proper service", and there is also a narrow exception for the use of small firearms by medical facilities in war zones if "they use the arms in their own defence, or in that of the wounded and sick in their charge".

Even if there is strong evidence of military activity at the hospital that substantially exceeds these exemptions, strict rules that limit how force can be used still apply; civilians must be given the chance to evacuate, and civilians who remain in the building are still protected and cannot be targeted directly. Prior to the raid, Israel called for the evacuation of the hospital, but on 13 November doctors refused to do so, saying that they had to remain in order to tend to over 700 at risk patients. According to Hamas, civilians were unable to evacuate due to sniper fire and drone attacks.

Initial clashes and siege

On 3 November, an Israeli airstrike targeted an ambulance convoy leaving the hospital. The attack killed 15 and wounded 60. Israel stated that Hamas was using the ambulances. Neither the Washington Post nor the Human Rights Watch found anything to evidence the Israeli statements. The Palestine Red Crescent Society (PRCS) stated that Israel had targeted Al-Shifa ambulances 7 times prior and had killed 4 of their personnel. On 6 November, Israeli forces struck and destroyed the solar panels atop the hospital, leaving it fully reliant on back-up generators powered by rapidly dwindling fuel supplies.

On 10 November, at least four strikes hit various areas of the hospital with various projectiles. Israel stated that at least one projectile was a misfired militant rocket, but did not elaborate further. The Gaza Health Ministry (GHM) stated that there were at least 5 strikes damaging parts of the hospital complex,- two, at 2 and 8 am., hitting the maternity ward located on the upper floors,- stating that 14 people had been killed. Later a Palestinian doctor stated that 7 people had died following the strikes. On the same day, it was reported that Israeli forces were at the gates of the hospital.According to a follow-up investigation commissioned by the New York Times from experts who examined videos and remnants of the munitions, three of the projectiles fired at the hospital were Israeli.

On 11 November, the GHM stated that an evacuation was underway, that 50,000–60,000 people were sheltering in the hospital before, and that fewer than 3,000 people remained. Later that day, the PRCS stated that Israeli tanks were 20 meters away from the hospital. Doctors Without Borders (DWB) and the World Health Organization (WHO) stated that Israeli troops were shooting at those trying to exit the hospital, which Israel denied. Israel stated that they were letting people leave the hospital, which DWB denied. By this time, Al-Shifa ran out of fuel and had suspended some operations. As a result, 2 babies in incubators and two other patients died. The hospital director said that the hospital had electricity until the morning of 12 November, meaning that 37 babies in incubators are at risk of dying. The GHM stated that 100 bodies would be buried in a mass grave inside the hospital.

In a series of comments with Al Jazeera, Muhammad Abu Salmiya, the director of the hospital, said that the hospital was cut off from the rest of the city, trapping a reported 15,000 people inside. He also added that "patients were dying by the minute, victims and wounded were also dying, even babies in incubators."

The Israeli military denies the siege of Al-Shifa after one of the senior Israeli military officials issued a statement. The official stated that there wasn't any shooting or siege, and that the east side remained open.

On 12 November, the WHO lost contact with the hospital. The hospital director said that premature babies were in a 'precarious situation' and that they were transferred to an 'unhealthy location'. At this time, power was completely cut off in the hospital. Minister of Health Mai Al-Kalia stated that over 100 bodies were buried in the graveyard, however the medical teams were unable to make a mass grave in the courtyard due to the 'seriousness of the field situation.' She also added that 39 babies were at risk of death and that one baby died that morning due to lack of fuel. Doctors in Al-Shifa Hospital reported snipers at the outskirts of the complex were firing at "any moving person".

Hamas officials had reported to Agence France-Presse that the cardiac ward was struck by Israeli air strikes, which was confirmed by witnesses but not by AFP.

On 12 November, Israel attempted to provide 300 litres of fuel to the hospital, which they say was blocked by Hamas. In response, a spokesperson for the health ministry stated that Al-Shifa needed 8000-12000 litres of fuel to run for a day, and that 300 litres would keep the hospital running for half an hour. Additionally, hospital staff noted there was no way to receive this fuel, as no ambulances were arriving at Al-Shifa and risk getting caught in crossfire, urging that the only way to safely access the fuel was with a pause in fighting.

On 13 November, about 50 people tried to evacuate from the hospital, but they said that Israeli forces fired at them, wounding one man.

15 November raid

Just after midnight on 15 November, Israeli forces informed officials that they would shortly be raiding the hospital. Hospital staff reported sounds of clashes from outside the grounds, and Israel reported killing several Hamas militants outside of the grounds.

Following the raid, Israel stated that they had delivered supplies to the hospital, including battery-powered incubators, medical supplies and baby food. Reuters verified that a photo of boxes labelled as medical supplies and baby food was taken inside the hospital. Israel also reported finding weapons and other "terror infrastructure" within the hospital; "concrete evidence", they said, of Hamas using the hospital as a "terror headquarter". According to the BBC, an Israeli official said that Israel had found weapons and terror infrastructure but did not immediately provide evidence.

According to a journalist inside the hospital, Israel was interrogating people within the hospital on Wednesday morning, including doctors and patients. According to a witness, Israeli forces fired a smoke bomb into the hospital that "caused people to suffocate", while a spokesperson for the Gaza Health Ministry said "The occupation army is now in the basement and searching the basement. They are inside the complex, shooting and carrying out bombings." Munir al-Bursh, the general director of Gaza hospitals, told Al Jazeera, "Patients, women and children are terrified."

Evacuation

On 19 November, the World Health Organization evacuated 31 premature babies while more than 250 critically ill or wounded patients remain trapped at the hospital. Doctors Without Borders said Israeli forces had on 18 November fired "deliberately" on a clearly marked convoy carrying 140 of the organization's employees and family members. More than 2,500 people also evacuated.

Alleged military use

There have been allegations that Hamas has been using the Al-Shifa Hospital for military purposes. Izzat al-Risheq, a Hamas official, denied allegations that the group was using Shifa Hospital as a shield for its underground military structures, saying there was no truth to the statements.

On 14 November 2023, the U.S. National Security Council spokesperson, John Kirby, said that the United States had its own intelligence sources indicating that Al Shifa hospital was being used by Hamas to run military operations and store weapons, which constitutes a war crime. The intelligence included communication intercepts of Hamas fighters inside the hospital complex.

Al-Shifa staff had appealed to the international community to send international delegations to the hospital to see that no military actions were taking place in the hospital.

The IDF released photos showing "Military uniforms, 11 guns, three military vests, one with a Hamas logo, nine grenades, two Qurans, a string of prayer beads, a box of dates." Former US State Department legal advisor Brian Finucane said "These arms by themselves hardly seem to justify the military fixation on al-Shifa, even setting the law aside".

Following the release of the Israeli photos, Al Jazeera senior political analyst Marwan Bishara was skeptical, since Hamas left the guns and nothing else. Bishara added that Israel doesn't have any evidence that justifies "the genocide that they've carried out against Gaza and the bombings of the hospitals and other facilities and for the collective punishments."

Mouin Rabbani, a Middle East analyst, stated to Al Jazeera, "Israeli forces have invaded Shifa Hospital and been inside it for 12 full hours – having refused any independent party to accompany them – and now we're supposed to believe that there were Hamas militants in there being pursued by the Israeli military but they somehow left their weapons behind?"

Israeli forces continued to search the facility for a second day, unearthing what they described as a tunnel entrance on the perimeter of the hospital complex, although they have yet to enter due to fear of booby traps and it may be days before they do so. New York Times journalists visited the site and verified that a concrete shaft descending into the earth existed, and that electrical wiring and a ladder was visible, although they were not able to determine how deep the shaft was or where it lead. The military said the search would take time. Investigative journalist Jeremy Scahill stated that the "Israelis have a multidecade track record of lying, of promoting false information, releasing doctored videos". He then stated regarding the evidence that he had seen more guns in the homes of Americans than in this purported Hamas Pentagon under al-Shifa Hospital. Netanyahu stated in an interview with CBS that the Israeli government had "strong indications" that hostages were in al-Shifa, which was one of the reasons they entered the hospital, adding that "I think the less I say about it, the better." On 16 November, the IDF reported that the body of Yehudit Weiss, a 65-year old woman who was captured from Be'eri kibbutz, had been located in a structure nearby to the hospital. On 17 November, the IDF had discovered the body of 19-year-old Cpl Noa Marciano in a building next to the hospital.

Jeremy Bowen, BBC News' international editor, noted that there is no independent scrutiny inside the hospital, since journalists are working under the aegis of the Israeli military. He also stated that the evidence that was produced wasn't convincing enough to prove that "this was a nerve centre for the Hamas operation". On 17 November 2023, journalists for The Independent stated that "Israel has not presented evidence that shows a large-scale headquarters under the hospital". CNN analysis suggested Israel had rearranged the weaponry before allowing press into the hospital.

On 19 November the IDF released footage down the tunnel shaft of what it stated to be a Hamas tunnel network. The footage showed a tunnel shaft, which contains a winding staircase approximately three meters deep and it continues for seven meters down until it reaches part of a tunnel network. The tunnel continues for five meters before turning right and continuing for another 50 meters. At the end, there is a blast door and what the IDF says is a gunhole. Mounir El Barsh, the Gaza health ministry director, stated the Israeli tunnel statement was a "pure lie" and that the IDF had already been on the al-Shifa complex for eight days. Later that day, the IDF also published surveillance footage taken by the hospital's cameras, showing a group of men forcibly bringing two hostages into the hospital. The hostages were identified as two foreign hostages captured during the 7 October attack. Hamas didn't respond, but in the past they stated that they have taken hostages to hospitals for treatment.

On the same day, CNN visited the tunnel shaft and confirmed that a tunnel existed near the hospital, describing a substantial shaft descending 10 metres into earth that included a central column that looked like a hub for a spiral staircase; according to a video shown by the IDF, deeper in the shaft such a spiral staircase did exist. Both Hamas and health officials had denied that a tunnel network existed beneath the hospital. After inspecting the tunnel network, Haaretz reported that "The question of whether Al-Shifa's managers knew about the tunnels, the munitions and the military headquarters is answered the moment you go down into the tunnel with the IDF – one stretch is 170 meters long. There is no way the hospital administrators didn't know what was happening…The tunnels lead to well-lit, air-conditioned rooms that contain tables and beds. It's not clear if these rooms were prepared to receive hostages, but there is no doubt they were used by Hamas company, battalion and brigade commanders, and that fighting was directed from there in recent rounds, if not in the current war as well."

On 20 November, former Israeli Prime Minister Ehud Barak, referring to Israeli built bunkers from decades ago, told CNN "It's already [been] known for many years that they [Hamas] have the bunkers that originally [were] built by Israeli constructors underneath Shifa [which] were used as a command post of Hamas. And, a kind of junction of several tunnels are part of this system." According to Israeli officials, Hamas subsequently dug out the original basement, later adding new floors and connecting it as a hub within their existing tunnel system. A France24 investigation concluded that the images and videos of the tunnels published by the IDF were consistent with Hamas built tunnels. They also note that the tunnels were found under the Qatari building, which was built after Israel withdrew from Gaza.

The Washington Post analyzed the publicly released material by Israel, along with satellite imagery and other publicly available material, and concluded that the rooms that were connected to a tunnel network did not show any immediate evidence of being used by Hamas, and that each of the buildings that the IDF spokesman Daniel Hagari had identified as being "directly involved" in Hamas's military activity did not appear to be connected to any tunnel network, and that there had been no evidence released that showed that a tunnel network could be accessed from within the hospital's wards.

Impact and casualties

The situation at al-Shifa Hospital is part of a serious healthcare crisis in Gaza. The hospital is rapidly running out of electricity, food and medical supplies. The last generator ran out of fuel, killing three premature babies and four other patients. By 19 November, the hospital had no antibiotics or painkillers to treat its patients.

By 12 November, two critically ill patients in the ICU had died because of a lack of electricity and oxygen.

According to a doctor at the hospital quoted in a 15 November BBC article, six premature infants had died, as had a critically ill adult burn victim. The doctor attributes these deaths to a lack of fuel for incubators, oxygen, and other essential medical equipment. Another doctor at the hospital, Ahmed Mokhallalati, said that 43 of the hospital's 63 intensive care patients had died because the intensive care unit ran out of oxygen.

The blockade has resulted in a humanitarian disaster, with numerous Palestinians seeking refuge in medical facilities. The toll on civilians, particularly children, has been extensive, with almost half of Gaza's hospitals shutting down due to acute fuel scarcity. The hospital has had to provide makeshift housing, and the absence of clean water and sanitation services is exacerbating the transmission of infectious diseases.

Amidst the siege, Hamas suspended hostage negotiations due to Israel's takeover of al-Shifa Hospital and heavy fire as Israeli forces approached the facility.

Gaza officials said an airstrike destroyed the hospital's cardiac ward, while a power cut shut down the neonatal unit's incubators where around 40 children were hosted and ventilators for others receiving urgent care.

On 19 November, the 31 remaining premature babies receiving care at al-Shifa Hospital were transferred to Emirati Hospital in Rafah, escorted by the Palestinian Red Crescent and other health organizations. 28 of the babies were evacuated to Egypt on 20 November.

Israeli media campaign

Before and after the siege, the Israeli government engaged in a public relations campaign aimed at justifying its siege and takeover of the hospital. On 11 November, the Israeli Ministry of Foreign Affairs tweeted a video purportedly of a nurse at al-Shifa in which she backs up Israeli statements regarding Hamas usage of the hospital. The Nation described the campaign as propaganda, and stated that the video was widely mocked, with many Arabs questioning its authenticity, and the ministry deleting the tweet in a day. The Daily Beast, remarking on the video, said "Everything about it smacked of high school theater—from the botched accent that sounded like it was straight out of an Israeli soap opera to the perfectly scripted IDF talking points rolling off her tongue." France 24 found the video to likely be staged. Subsequently, France 24, citing three experts, Michael Milshtein of Tel-Aviv University, Scott Savitz, an Engineer, and Daphne Richmond-Barak of Reichman University in Israel, found the Israeli-released footage of tunnels beneath Shifa hospital "do indicate that these tunnels have all the characteristics of tunnels that belong to the Hamas terrorist group."

Some experts have said that questionable evidence such as stating that an Arabic calendar was a Hamas shift schedule, and displaying curtains as evidence that hostage videos were filmed has weakened Israel's credibility, with H. A. Hellyer stating “The irony is they might find something and nobody is going to believe them, at this point their credibility is shot." Adding "We don’t take seriously what a terror group says, but we do take seriously what an army says, especially one that’s an ally of ours,” he said. “So we naturally hold it to a higher standard.” Muhammad Shehada, Euro-Mediterranean Human Rights Monitor Chief of Programmes and Communications, said of the requirements that Israel imposed on media outlets on their supervised tours of al-Shifa that the outlets have essentially agreed to broadcast propaganda, saying of the outlets "You are not allowed to speak to any Palestinian or Gazan to challenge what the IDF is spoon-feeding you. You are not allowed to go beyond the tour that the IDF has staged, so you stick to what the IDF wants to show you and where they take you. And you have to review the material with them before you publish, so that the result of that is not journalism. It’s propaganda."

The New Arab, describing the ongoing propaganda campaign and how it has backfired with people questioning Israel's credibility, wrote that Israel had "resorted to fake audio, baseless claims and doctored imagery to whitewash its attack in Gaza." They discussed how the failure of the incubators in the Neonatal intensive care unit of al-Shifa caused by the denial of fuel deliveries by Israel and the cutting of electricity was responsible for the deaths of three prematurely born babies. Israel, while it had caused the fuel shortage and failure of the existing incubators, made a show of delivering new incubators to the hospital. However, the issue was not with the incubators, it was with the lack of fuel, an issue that was not addressed.

Following Israel's release of video evidence on 22 November, the Associated Press, the New York Times, the Wall Street Journal, the Guardian, Sky News and Amnesty International all concluded that this did not constitute sufficient evidence to demonstrate the use by Hamas of a command center. Haaretz concluded that Hamas did use the hospital for military purposes.

Reactions

Government

China has described the struggling hospital as a manifestation of the humanitarian crisis in Gaza. The Palestinian Minister of Health, Mai al-Kaila, described Israeli actions as a "crime against humanity." Israel disputes this, stating that it does all it can to protect civilian life, and that it is Hamas that puts civilians in harms way by blocking their evacuation from combat zones. US President Joe Biden stated Gaza's hospitals "must be protected." Biden accused Hamas of committing a war crime by allegedly having its headquarters under al-Shifa Hospital, with The Nation noting that Biden appeared "unfazed by the flimsiness" of Israel's "ludicruous propaganda".

Prime Minister of Canada Justin Trudeau stated, "Even wars have rules... I urge the government of Israel to exercise maximum restraint... The world is witnessing this, the killing of women and children, of babies. This has to stop." Ayman Safadi, the Jordanian Minister of Foreign Affairs, condemned the attack, stating, it was a "violation of international humanitarian law, especially the 1949 Geneva Convention relative to the Protection of Civilian Persons in Time of War." Qatari foreign minister, Mohammed bin Abdulrahman bin Jassim Al Thani, stated the siege was a "war crime and a blatant violation of international laws." The Saudi Arabian foreign ministry stated it "strongly condemns the Israeli occupation forces' storming of al-Shifa Hospital in Gaza."

Academics

H. A. Hellyer, a fellow at the Carnegie Endowment for International Peace, stated a huge trust deficit remained regarding Israeli intelligence, and that Israeli statements should not be taken at "face value." Sultan Barakat, a professor at Hamad Bin Khalifa University in Qatar, stated US and Israeli information on Gaza was not reliable. Osamah Khalil, a professor at Syracuse University in New York, deemed it improbable that Hamas would have a base at Al-Shifa, as the hospital was one of the busiest places in Gaza.

Media

Antony Loewenstein noted Israel has a long history of "deliberately targeting medical facilities in the West Bank, East Jerusalem and Gaza," and that IDF statements about military facilities needed to be "treated with deep scepticism." Palestinian analyst Thabet Al-Amour stated, "This is madness, absolute madness… It's a hospital." Al Jazeera journalist Hamdah Salhut stated Israel had not shown "solid proof, or evidence" to back up their statements.Major-General Giora Eiland, former head of the Israeli National Security Council, stated that targeting the hospital was tactical,- aiming to control the narrative about Hamas rather than serving a strategic purpose. An analysis by The Washington Post found Israel's evidence "falls short" of proving the hospital was a command-and-control centre.

Organizations

The World Health Organization (WHO) confirmed that Al-Shifa Hospital is without electricity, putting patients, including children, at risk of death. WHO director-general Tedros Adhanom Ghebreyesus said on social media that al-Shifa had been without water for three days and was "no longer functioning as a hospital". Doctors Without Borders reported that an ambulance and the patients inside were attacked near the hospital. A spokesman for the International Red Cross and Red Crescent Movement stated, "I cannot even imagine … the panic among the patients, the panic among doctors and nurses. What they're [going] through is really something that is unbelievable."

A group of Israeli doctors, known as Doctors for the Rights of Israeli Soldiers, has signed a statement advocating the bombing of Al-Shifa hospital. The statement was publicly signed by dozens of Israeli doctors and was widely shared on various social media platforms. The doctors stated that it was Israel's "legitimate right" to bomb al-Shifa hospital because it served as a base for "Palestinian armed groups". Alice Rothchild, the director of Jewish Voice for Peace, stated noted Israel's lack of hard evidence of military operations at al-Shifa, stating, "Israeli sources have a long history of not being very accurate."

See also

• Al-Ahli Arab Hospital explosion
• Attacks on health facilities during the 2023 Israel–Hamas war