There鈥檚 No Justification for Destroying Gaza鈥檚 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 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 鈥淕aza鈥� or 鈥済enocide鈥� 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鈥攎uch to their surprise鈥攈ow many people in leadership roles in their institutions support , even when health care workers and hospitals are targets.

We wrote the following essay in response to JAMA鈥檚 promotion of ethical ambiguity around bombing hospitals. It was rejected for publication鈥攜et another act of institutional silencing. As Israeli media now tours the Gaza hospitals that Israel destroyed, alleging these were military targets, we see . But we do see thousands of dead patients鈥攎any of them children鈥�and hundreds of as a result of .

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 鈥�,鈥� by Matthew Wynia, in JAMA. Far from speaking hard truths in the face of dehumanization, violation of medical ethics, and war crimes, 奥测苍颈补鈥檚 framing is a stunning example of 鈥�,鈥� a foundational strategy to justify war and obstruct peacemaking. To engage popular support for war, nations, their militaries, and their institutions to coerce acceptance for atrocities. Ignoring history, power, and context, 奥测苍颈补鈥檚 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.

奥测苍颈补鈥檚 article was published as the world is witnessing , under Israel鈥檚 justification of unverified claims that these Days before the JAMA publication, Israeli physicians provided cover, calling for the in Gaza. The combined effect of of Gaza with airstrikes, ground warfare, and complete siege blocking food, medicine, water, and fuel since Oct. 9 has caused the collapse of Gaza鈥檚 health care system. As we write, newborns in a neonatal ward are , 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, 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 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 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.

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鈥檚 meeting of the House of Delegates on Nov. 11 was emblematic of medicine鈥檚 institutional response to this direct assault on our profession. The 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鈥� 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 that was in the same service of racial capitalism as apartheid in South Africa. Wynia appeals to our humanity by highlighting Hamas鈥� 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鈥檚 targeting of hospitals in Gaza. Specifically, Wynia says, 鈥淚srael says it is abiding by these rules, but some international law experts believe Israel is not doing all it should to avoid harming civilians,鈥� and adds, almost as an afterthought, that 鈥渟ome believe Israel鈥檚 siege of Gaza amounts to 鈥榗ollective punishment,鈥� which is a war crime too.鈥�

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: 鈥淗ealth professionals of goodwill and equally strong commitments to human rights have differing opinions on these questions, which reflects the nature of the questions.鈥� This statement corrodes the ethical foundations of the medical profession. It also belies our profession鈥檚 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 鈥渞easonable people disagree鈥� about the question of killing injured children who are seeking medical care. There is no moral ambiguity to preventing . Unfortunately, . The , 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: .

There should be no ambiguity. From a legal perspective, and are clearly war crimes. Israel is leaning on the Rome Statute of the International Criminal Court鈥檚 legal loophole for bombing hospitals, schools, and other places where the sick and wounded are gathered by stating that these locations are protected, 鈥�.鈥� Fascist armies have used this logic before, which led to the Geneva Convention鈥檚 articles protecting health care in times of war in the first place. In 1935, , claiming they were housing militants. In Mussolini鈥檚 world, anything that was not in the interests of Italy鈥檚 fascist regime was considered a .

This line of reasoning creates a narrative space where the most sacred aspects of our work as physicians鈥�caring for the sick and vulnerable, regardless of identity鈥�is left open to the kinds of attacks we are witnessing in Gaza and the simultaneous attacks on medical ethics exemplified in . 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.

Rupa Marya is a Professor of Medicine at the University of California, San Francisco and co-author with Raj Patel of聽Inflamed: Deep Medicine and the Anatomy of Injustice.聽Follow her on Twitter @DrRupaMarya

Dr. Leigh Kimberg is a聽Professor of Medicine聽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

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.

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