There’s No Justification for Destroying Gaza’s Health Infrastructure

As the health care system in Gaza collapses from more than seven weeks of targeted Israeli bombardment and complete siege, medical institutions in the United States have been silent. Worse, they have attempted to justify the violence. The Journal of the American Medical Association (JAMA) on Nov. 8, 2023, published an essay that we felt created moral ambiguity around bombing hospitals in Gaza.

We are physicians, and in countless private conversations with other physicians, nurses, and medical workers around the U.S., we hear whispers about people being afraid to lose their jobs if they show support for Palestinians. They have been instructed by their leadership not to say the words “Gaza” or “genocide” in their professional roles, while they watch Israeli forces bomb hospitals, murder health care providers, and assault ICU patients. Many health care workers are discovering—much to their surprise—how many people in leadership roles in their institutions support ethnonationalism, even when health care workers and hospitals are targets.

We wrote the following essay in response to JAMA’s promotion of ethical ambiguity around bombing hospitals. It was rejected for publication—yet another act of institutional silencing. As Israeli media now tours the Gaza hospitals that Israel destroyed, alleging these were military targets, we see no Hamas command center. But we do see thousands of dead patients—many of them children—and hundreds of dead medical workers as a result of Israel’s unprecedented violence.

As physicians, we understand that our work is sacred, and the places of our care are also sacred. There is never an ethical case to bomb hospitals. There is never an ethical case for genocide. We share our response with the larger public to break the silence, to reaffirm our professional ethics, and to encourage all health care workers to speak out and rise in solidarity with our Palestinian colleagues and the communities they care for.

NOTE: What follows is a lightly edited version of the original essay rejected for publication by JAMA.

There Is No Ethical Ambiguity About Bombing Hospitals

As physicians and health equity experts, we were disturbed to see the publication of “Health Professionals and War in the Middle East,” by Matthew Wynia, in JAMA. Far from speaking hard truths in the face of dehumanization, violation of medical ethics, and war crimes, Wynia’s framing is a stunning example of “narrative control,” a foundational strategy to justify war and obstruct peacemaking. To engage popular support for war, nations, their militaries, and their institutions enforce dominant narratives to coerce acceptance for atrocities. Ignoring history, power, and context, Wynia’s arguments introduce ethical ambiguity where there should be none: To be clear, there is no context where bombing hospitals full of sick and injured patients and the medical staff caring for them is acceptable.

Wynia’s article was published as the world is witnessing Israel destroying Gaza’s health care infrastructure, under Israel’s justification of unverified claims that these spaces host Hamas operations. Days before the JAMA publication, Israeli physicians provided cover, calling for the annihilation of all hospitals in Gaza. The combined effect of Israel’s 16-year blockade of Gaza with airstrikes, ground warfare, and complete siege blocking food, medicine, water, and fuel since Oct. 9 has caused the collapse of Gaza’s health care system. As we write, newborns in a neonatal ward are dying one by one, as power is lost for incubators due to the bombing.

These attacks on health care in Gaza are not a first for Israel. In 2021, Israeli airstrikes hit six hospitals and nine primary care centers, and destroyed a desalination plant that supplies clean water to a quarter of a million people. This past week alone, the Israeli army surrounded and bombarded several hospitals, killing or injuring health care workers, patients, and thousands of displaced people who had been sheltering in hospital corridors and courtyards. These targeted assaults on health care facilities, health care workers, and patients have led to the deaths of an estimated 192 health care workers and the incapacitation of 113 health care facilities (including 20 out of 36 hospitals in Gaza that are now out of operation), and have contributed heavily to the growing casualties in Palestine, which now top 11,000 people.

Doctors in Gaza are pleading on social media for international intervention to save them and the overflow of patients they refuse to abandon. Still, Israel continues its devastating assault unimpeded by the institutions that were built to prevent such atrocities. The American Medical Association’s meeting of the House of Delegates on Nov. 11 was emblematic of medicine’s institutional response to this direct assault on our profession. The Speaker forwent the traditional democratic process and silenced the two medical residents who brought the discussion of a cease-fire up for consideration. Silencing is the ultimate form of narrative control.

In this historic context, Wynia asserts that health professionals must oppose racism. In the first part of his article, he focuses our attention on antisemitism by reminding us of the Holocaust and medical professionals’ role in speaking out against war crimes, with which we agree.

The article then pivots to reinforce the dominant narrative that Israelis are the victims, despite decades of Israel enforcing an apartheid state on Palestinians that Nelson Mandela understood was in the same service of racial capitalism as apartheid in South Africa. Wynia appeals to our humanity by highlighting Hamas’ violence against Israelis while ignoring the evidence flooding the internet of mostly brown Palestinian bodies buried under rubble created through the actions of the Israeli government.

Wynia demands that we speak out against war crimes and is quick to denounce Hamas for launching attacks from inside or near medical facilities. But then, instead of denouncing Israel for doing the same or worse, he invokes legal justifications supporting Israel’s targeting of hospitals in Gaza. Specifically, Wynia says, “Israel says it is abiding by these rules, but some international law experts believe Israel is not doing all it should to avoid harming civilians,” and adds, almost as an afterthought, that “some believe Israel’s siege of Gaza amounts to ‘collective punishment,’ which is a war crime too.”

Wynia then asks a series of ethical questions probing the moral grounds to bomb hospitals where enemy combatants may be hiding among injured children. The ambiguity of his response is chilling: “Health professionals of goodwill and equally strong commitments to human rights have differing opinions on these questions, which reflects the nature of the questions.” This statement corrodes the ethical foundations of the medical profession. It also belies our profession’s historical allegiance to power.

From a medical ethics perspective, there is no circumstance in which hospitals where injured, ill people are being treated should be bombed. There is no ethical space where “reasonable people disagree” about the question of killing injured children who are seeking medical care. There is no moral ambiguity to preventing genocide. Unfortunately, JAMA has a habit of creating narrative ambiguity in places where historic dynamics of power and oppression operate. The history of medicine is a study in dynamics of power, a subject in which most physicians have neither critical analysis nor literacy. No better case study can be found than the issue of Palestine, where institutional medicine has a demonstrated record of narrative control: through censorship and silencing of Palestinian accounts.

There should be no ambiguity. From a legal perspective, attacks on hospitals and medical personnel are clearly war crimes. Israel is leaning on the Rome Statute of the International Criminal Court’s legal loophole for bombing hospitals, schools, and other places where the sick and wounded are gathered by stating that these locations are protected, “provided they are not military objectives.” Fascist armies have used this logic before, which led to the Geneva Convention’s articles protecting health care in times of war in the first place. In 1935, Mussolini’s armies attacked 20 Red Cross and Red Crescent field hospitals in Ethiopia, claiming they were housing militants. In Mussolini’s world, anything that was not in the interests of Italy’s fascist regime was considered a legitimate threat and a target.

This line of reasoning creates a narrative space where the most sacred aspects of our work as physicians—caring for the sick and vulnerable, regardless of identity—is left open to the kinds of attacks we are witnessing in Gaza and the simultaneous attacks on medical ethics exemplified in Wynia’s JAMA article. Opening the door to bombing hospitals, killing injured and hospitalized children, and framing it as morally and ethically ambiguous is a dangerous position for JAMA, putting the journal dangerously out of step with the world and the moral code at the heart of our profession.

	Jess H. Ghannam is Clinical Professor of Psychiatry and Global Health Sciences in the School of Medicine at UCSF. His research areas include evaluating the long-term health consequences of war on displaced communities and the psychological and psychiatric effects of armed conflict on children. Dr. Ghannam has developed community health clinics in the Middle East that focus on developing community-based treatment programs for families in crisis. He is also a consultant with the Center for Constitutional Rights, Reprieve and other international NGO's that work with torture survivors. Locally he works to promote and enhance the health and wellness of refugee, displaced, and immigrant populations from the Middle East,North Africa and South Asia and has established a community-based Mental Health Treatment Programs to support these communities. At UCSF Dr. Ghannam develops culturally competency training programs for staff, students and faculty working with patients from the Middle East. He serves as the faculty Co-Chair for the UCSF Center for Community Engagement. Dr. Ghannam works with medical students and residents across disciplines to promote and enhance their clinical, research and global health skills. Dr. Ghannam specializes in working with chronic illness, including chronic pain, PTSD and mTBI. He also works and does research in the area of Global Health and Post Traumatic Stress Disorder.
	Dr. Leigh Kimberg is a Professor of Medicine at the University of California, San Francisco (UCSF) She has practiced primary care internal medicine in the safety net healthcare system in San Francisco for three decades and does violence prevention work. Follow her on Twitter @LeighKimberg
	Rupa Marya is a Professor of Medicine at the University of California, San Francisco and co-author with Raj Patel of Inflamed: Deep Medicine and the Anatomy of Injustice. Follow her on Twitter @DrRupaMarya Connect: Twitter