URGENT Plea to American Health Institutions from Healthcare Workers (in USA): Condemn Attacks on Health in Occupied Palestine

We, the undersigned health professionals, in solidarity with our colleagues caring for victims of the ongoing conflict in Occupied Palestine and Israel, call on the U.S. health system including medical and public health professional entities, medical institutions, and academic medical institutions to denounce violence against health facilities in Israel and the Occupied Palestinian territories (oPT). We appeal to the following organizations:

• American Medical Association (AMA) and its state and local chapters
• American Public Health Association (APHA) and its state and local chapters 
• American Nurses Association (ANA) and its state and local chapters
• American Hospital Association (AHA) and its state and local chapters
• American College of Physicians (ACP)
• American Academy of Pediatrics (AAP)
• Institute for Healthcare Improvement (IHI)
• National Association for Community Health Centers (NACHC) and its state and local chapters

Acknowledging the ominous implications of suppressing individuals who voice their conscience, we implore the aforementioned institutions to safeguard health professional's right and solemn duty to voice ethical concerns. US health professionals expressing concerns about the current conflict have been subject to threats and punitive measures.^51,52,53 The intimidation they face, particularly amid the International Court of Justice deliberations on attacks on health in Gaza as an act of genocide, exerts a profoundly chilling effect. It is untenable to preserve ethics in our profession if we silence those who raise crucial moral and ethical concerns. We refuse to succumb to such coercion.

Physicians, nurses, paramedics, ambulance drivers, and other health professionals across the globe pledge themselves to provide life-saving care to the sick and wounded in their hour of need. Those dedicated to such humanitarian service deserve respect and protection. Nowhere is this protection more necessary than in conflict zones. This principle is enshrined in International Humanitarian Law under Rule 251 and Rule 262 and in the Geneva Convention.³ 

As healthcare workers across the spectrum, we dedicate ourselves to beneficence. Beneficence does not simply require we do no harm; instead, our obligation extends "to protect and defend the right of others, prevent harm, remove conditions that will cause harm, help persons with disabilities, and rescue persons in danger".⁴  The moral imperative that guides our everyday professional practice similarly requires we speak up at this moment against the targeted violence against Gazans and their healthcare system.

We call for an immediate and unconditional halt to attacks on health professionals, health facilities, and healthcare infrastructure in Gaza and the West Bank, and for all parties to ensure immediate, unrestricted and unimpeded flow of humanitarian aid to all individuals in occupied Palestine and Israel.

Background:

The occupation of Palestine by the government of Israel has been marked by persistent, systematic, and violent targeting of healthcare facilities, workers, infrastructure including public health services, and patients seeking medical care. These attacks include: 

• direct Israeli military assault including bombardment, siege, forced de-commission, and sniper attacks inflicting acute injury on a mass scale of the population, consisting mainly of children and women;
• deliberate creation of public health conditions that harm health through mass starvation, disease, disability, and death; 
• long-standing, targeted, and systematic destruction of health infrastructure; 
• detention of medical personnel.

Direct Military Assaults on Health : 

We unequivocally condemn attacks on civilians in Israel by armed Palestinian fighters during the attack by Hamas on October 7, 2023.

Since Israel's bombardment of Gaza began following October 7, 2023, the world has witnessed hundreds of documented attacks on healthcare workers, facilities, and transport vehicles essential to access health services including rescue, recovery, and emergency transport. According to the United Nations special rapporteur, as of December 7 [2023], "at least 364 attacks on healthcare services [had] been recorded in the occupied Palestinian territory since 7 October 2023, resulting in at least 553 people killed and 729 injured. More than 50 health facilities and 190 ambulances have also been affected".⁵ 

Israel's direct assaults on health facilities in the Occupied Palestinian territories began well before October 7, 2023. Since October 2023, the Israeli Defense Forces' (IDF) targeting of medical facilities has been so systematic that, as of December 21, 2023, the World Health Organization (WHO) reports there are no fully functional medical facilities in northern Gaza, and only nine facilities left to serve over 2 million people (all in southern Gaza).⁶ Some examples of the assaults occurring since October 7, 2023 are as follows:

• In the first four days of Israel's bombardment, the WHO documented 33 attacks on healthcare targeting of 19 medical facilities, damaging 20 ambulances, and killing or injuring over two dozen individuals including medical personnel.⁷
• On October 10, 2023, the IDF attacked Indonesian Hospital resulting in the death of a medical professional and destruction of the oxygen station. Nasser hospital was also targeted with damage to 20 ambulances.^8,9
• The IDF has repeatedly ordered the evacuation of hospitals at short notice under threat of bombardment, with medical personnel often refusing to abandon patients.^{10,11,12,13,14,15,16}
• The IDF has ordered evacuations at short notice (e.g. within 48 hours) under threat of aerial bombardment without regard to the risk to patients.^{10,11,12,13,14,15,16} This includes premature neonates dependent on incubators made nonfunctional by the cutting off oxygen supplies and power to medical facilities. A number of premature infants in at least two different hospitals (Al Shifa and Nasser Hospital) perished as a result of military targeting.^17,18
• In the wake of IDF evacuation orders, reports of individuals being fired at upon their attempt to leave the hospital environs where they sought shelter discouraged individuals from complying with these orders, according to the international physician group Doctors Without Borders.¹⁹
• Hospitals in both Gaza and the West Bank have been surrounded by Israeli tanks, cutting off supplies.^20,21
• In at least one reported case, healthcare workers were used as human shields by raiding IDF forces.²²
• Medical personnel have been detained in large numbers by the IDF.^23,24
• There have been repeated attacks targeting ambulances and the communication systems they depend on to effectively function.^25,26
• By cutting off food, water, and fuel along with attacks on telecommunication and power sources and refusal of unimpeded humanitarian aid, medical personnel have been left to conduct trauma surgery without anesthetics and other proper medications and supplies.²⁷

Creating conditions that harm health through mass starvation, death, and disease:  

A key element of Israel's military campaign since October 7, 2023 includes completely cutting off clean water, food, and energy to the entire population of the Gaza strip.²⁸  This effort amounts to a planned, systematic dismantling of the public health infrastructure for 2.3 million Gaza residents. Starvation as well as infectious and waterborne diseases are increasing as a direct result of these actions. ^29,30 Bombardment causing permanent destruction to a significant portion of available shelter and healthcare facilities coupled with the simultaneous blockade of a consistent supply of healthcare and humanitarian aid, has resulted in sustained, serious, and likely irreversible harm to the health of all Gazans.³¹ 

Targeted, systematic destruction of healthcare: 

As of January 15, 2024, over 24,000 people have been reported killed in the Occupied Palestinian territories as a result of direct military action.³²  Of these deaths, an estimated 9,600 are children and 6,200 are women.³³   These numbers do not include Gazans presumed dead or those injured, nor do these numbers consider, from a public health-perspective, the estimated 1.9 million Gazans displaced.³⁴

Concerning healthcare worker casualties, the UN reported 296 Palestinian healthcare workers killed while providing care as of mid-December 2023. An additional 135 UN and WHO healthcare workers have been killed since October 7, 2023.35 Hundreds of the Palestinians killed in their homes by Israeli bombardment were healthcare workers,³⁶ and at least one American mainstream media outlet reported 200 health workers killed as of early December 2023.³⁷

Attacks on health in the Occupied Palestinian territories are not a new phenomenon. A blockade imposed by the government of Israel on Gaza since 2007 has severely undermined healthcare, resulting in depletion of essential pharmaceuticals and bans on imports of medicines ranging from anesthetics to the COVID-19 vaccine.^{38, 39} Medical devices and essential equipment such as radiological and endoscopy equipment (and their repair parts) are systematically prohibited to Gazans, deliberately damaging healthcare delivery so severely that the Gaza health sector is "in an ongoing state of emergency" and "always on the edge of collapse" according to the Palestinian Center for Human Rights.⁴⁰

Detention of Medical Personnel: 

According to Insecurity Insight, as of November 30, 2023, Israel has arrested at least 129 medical personnel in the Occupied Palestinian territories since October 7, 2023.^{36, 41}

Following the IDF's military incursion into Al Shifa hospital, there were reports of multiple arrests of healthcare workers at the hospital and additional reports of their use as human shields.^{41, 42} Director of the hospital, Muhammad Abu Salmiya, was taken into custody at a Israeli checkpoint after a seven hour detention of a UN convoy evacuating hospital patients following the IDF assault on Al Shifa Hospital.⁴³ 

Mass arrests and killing of medical personnel in an active conflict zone subject to systematic bombardment on a massive scale make it impossible for civilians to get healthcare, not only during this acute stage of conflict, but persisting far into the future. Without adequate healthcare, the conditions of life itself are being thrown into jeopardy.

Why U.S. Public Health institutions must Act:

By failing to speak out unequivocally in the face of a pattern of such egregious transgressions, public health institutions in the U.S. risk putting their own credibility, national and international reputation at stake. There is moral hazard in speaking of healthcare as a human right (as the American College of Physician endorses), decrying systemic racism as a public health crisis (as the American Medical Association does), championing the role of social determinants of health (as the Institute for Healthcare Improvement does), and promoting health equity (as the American Public Health Association does) here in the United States, while turning a blind eye to the systematic, violent and concerted dismantlement of health infrastructure administered by siege, bombardment, and direct military action aimed at those providing and receiving healthcare in Gaza and the West Bank.

The United States is using its enormous wealth to finance a military strategy to attack healthcare in the Occupied Palestinian territories. Since Israel's formation 75 years ago, 130 billion U.S. dollars have been provided to Israel for its security and defense. Further, a steep boost in aid has been proposed by our federal officials in the wake of October 7, 2023.⁴⁴ The U.S. Government has long ignored its own laws barring continued foreign aid to parties guilty of  human rights violations, when it comes to Israel, with government officials themselves expressing dissent and at least one State Department official even resigning in protest as the U.S. sharply increased military aid to Israel with "no red lines" after October 7, 2023.^45,46,47 When existing restraints are violated in this manner, speaking up becomes an obligation, especially for healthcare professionals who take an oath to make a solemn commitment to uphold the sanctity of life and prioritize the well-being of those in need.

The U.S. continues to fund the violent dismantling of Palestinian healthcare systems even as it fails to underwrite universal access to healthcare at home. It is disconcerting to observe how our hard-earned taxpayer dollars are being squandered on depriving those in Gaza of healthcare. Instead of contributing to destruction abroad, these funds should be judiciously employed to bolster and construct robust healthcare systems domestically, addressing the pressing needs of the American population. It is an egregious misuse of financial resources that demands immediate scrutiny and rectification. 

Health professionals have a duty to society to speak up in the face of such glaring dissonance.  Increasingly, we recognize the erosion of trust as an additional cause of worsening health disparities. Our failure to speak up against human rights violations in the past has seriously marred trust in our profession, particularly with minority and marginalized communities. In the infamous Tuskegee experiment, U.S. public health institutions withheld syphilis treatment for African Americans in the American South - and continued to do so for 29 years after a known treatment was available - with physician and public health institutions' knowledge and complicity. It was not until a social worker leaked the story to the press that public outcry finally stopped this horrific injustice.^48,49,50

Institutions are compounding their complicity as they silence individual members speaking their conscience.^51,52,53 Failing to speak now risks permanently disintegrating ethical, legal, and moral standards altogether, such that U.S. health professionals could be subject to unacceptable attacks in a future conflict.

Today, our silence risks perpetuating violence once again. The anguish we feel in the face of the escalating crisis in Gaza transcends professional boundaries. It's a deeply personal anguish stemming from a profound moral obligation to heal and alleviate suffering - a duty that seems tragically elusive in the current circumstances. Lest our very vocation evanesce, we call on the public health and professional organizations representing us to take a clear and unequivocal stand against attacks on healthcare workers in conflict zones, including in the Occupied Palestinian territories and Israel. 

By adding my signature, I affirm that I am a healthcare worker and  endorse this petition.

(ONLY FOR HEALTHCARE WORKERS IN USA)

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Bibliography

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