Several projectiles have landed inside the hospital complex in recent days, sparking panic among the chaos. On Friday, at least six hospitals in Gaza City reported being under siege or close to heavy urban combat.
“We expect the hospital and those inside it to be bombed at any moment,” Muhammad Abu Salmiya, the director of al-Shifa Hospital’s medical complex, said earlier Friday. “Medical teams will not leave the hospital and will not abandon the patients inside of it.”
The Gaza Health Ministry says at least 11,078 people have been killed and more than 27,490 wounded since a deadly Hamas attack inside Israel plunged the country into war. Israel’s military operation now aims at ending the group’s 16-year rule in Gaza once and for all, with an air campaign more withering and extensive than any it has ever launched, dropping thousands of explosives in just 31 days.
The threshold for civilian casualties appears higher than in previous operations, according to legal experts, as military planners frame the fight against Hamas as existential.
International law requires militaries to make clear distinctions between civilians and militants, and to take all possible precautions to prevent civilian harm. In practice, Israeli strikes have hit water towers and bakeries, schools and ambulances. Human rights groups have flagged a growing number of strikes as potential war crimes and pressed for an international investigation.
A major strike on al-Shifa Hospital, with patients still inside, would generate a wave of global outrage. “The health system is on its knees,” the head of the World Health Organization, Tedros Ghebreyesus, said at a briefing for the U.N. Security Council on Friday.
He then called the situation inside Gaza hospitals “impossible to describe,” with medical workers “directly in the firing line.”
On Friday, a spokesman for the Israel Defense Forces (IDF), Richard Hecht, said the Israeli army would take precautions “to make sure we don’t come in and raid people on drips or with broken bones.”
But it was unclear how such precautions would be possible. Only the most critical departments are still operating, Salmiya told the Al Jazeera news network Friday: intensive care, the neonatal and dialysis units, and the operating theater.
Wounded patients have severe burns, amputated limbs and internal bleeding, hospital staff say. Infections are spreading, according to Ghassan Abu-Sitta, a plastic and reconstructive surgeon working in the hospital, complicating any evacuation efforts.
“This isn’t something you can debate. Moving patients out of these units before they are ready would be akin to murder,” a humanitarian worker who visited the hospital this week said, speaking on the condition of anonymity because they were not permitted to speak with media.
Even if moving patients was possible, the Palestinian Red Crescent Society said it’s unable to operate its ambulance fleet. “The ambulances are unable to drive because of the continuous bombardments in Gaza City,” PRCS spokesperson Nebal Farsakh said. “The medics can see wounded people in the streets, but they are unable to save them.”
The IDF laid out its most comprehensive set of allegations regarding Hamas activities at al-Shifa Hospital late last month.
“The Hamas terrorist organization has continued operating below Gaza’s Shifa Hospital, using the thousands of patients, doctors and staff in the building to shield its underground headquarters,” the IDF said in a statement.
It included what it said was an “intelligence-based video” with illustrated 3D models of the area below ground. It also released a recording of what it said were two unidentified Palestinians speaking on the phone, in which one tells the other that Hamas is headquartered at the hospital. It was not possible to verify the authenticity of the recording.
A senior Israeli security official, speaking on the condition of anonymity to discuss sensitive matters, said Israel shared its intelligence on al-Shifa Hospital with other governments, including the United States and the European Union. “We will not let it be a sanctuary,” the official said of the hospital.
Israeli authorities have shared with the Biden administration their assessments that many Gaza hospital facilities — and al-Shifa in particular — are tightly integrated with Hamas’s operational infrastructure in the territory.
The Biden administration views the Israeli intelligence as credible, senior administration officials have said in recent days, although their independent information is limited because the United States has not extensively focused on Hamas in recent years. The officials spoke on the condition of anonymity to be frank about their communications with the Israeli government.
Hamas is known to have built an extensive network of tunnels throughout Gaza, including under civilian infrastructure, leading Israeli and Western officials to accuse them of using the enclave’s 2.3 million people as human shields.
Amnesty International also said in 2015 that Hamas militants had subjected opponents to interrogations, torture and other forms of abuse inside a disused outpatient clinic within al-Shifa Hospital grounds during the war the previous year.
Hamas officials have denied the accusations and said they would welcome an inspection by international observers. In an interview in Beirut on Friday, Hamas spokesman and former health minister, Basem Naim, called the Israeli allegations “false.”
“It’s a small space and all the journalists are there,” Naim said of the hospital. “If we were doing secret military resistance work, would we be in a place that has journalists of all types?”
But even if a single room was in use for military purposes, legal experts say, most modern militaries would still consider the risk of significant collateral damage too great.
The Biden administration has repeatedly urged the Israeli government in recent days to consider the proportionality of their actions and to take care to protect civilian lives as they pursue Hamas targets. In some cases, officials say, that has meant considering the negative publicity associated with hitting ambulances, even if they believe Israeli evidence that specific strikes have targeted Hamas operatives.
Doctors past and present who have worked al-Shifa Hospital have strenuously denied allegations that the hospital has been used for any military purpose during this war. Foreign medics who carried out multiple residencies or voluntary stints in the facility said the same.
“We would be there from early in the morning until late at night and I’ve never once seen military activity at the hospital,” said Anna Vergun, an orthopedic surgeon from Chapel Hill, N.C., who has volunteered on a program for amputees at the facility since 2016.
“It’s a busy hospital dedicated to caring for patients and I’ve never seen any member of Hamas or the police present,” said Ihab Halaweish, an Egyptian American pediatric surgeon who left Gaza City on Oct. 6, the day before the war started, after volunteering at al-Shifa Hospital for two weeks.
All medical facilities are protected under international law, unless they are used for military purposes. But even then, there are limits to what an attacking force is allowed to do.
“The principle of proportionality prohibits armies from inflicting civilian casualties that are ‘excessive’ in relation to the direct military advantage anticipated at the time of the strike,” said Brian Finucane, a senior adviser at the International Crisis Group who has advised the U.S. government on counterterrorism and the use of military force.
“But prior to attacking a hospital, which is being used to commit acts harmful to the enemy, a warning must be issued,” he said.
Israeli officials have repeatedly called on Palestinian civilians to leave northern Gaza — including Gaza City — for the south, and the IDF has set up “protected” corridors in recent days to allow residents to evacuate on foot.
But in practice, those who are too wounded or infirm to move have been unable to heed that call. Others have argued, with merit, that nowhere else is categorically safe earlier: Israeli bombing raids have targeted almost every area in the strip.
“The warning issued by the Israeli government is ineffective because there is no safe place to go in Gaza,” said Omar Shakir, the Israel and Palestine director at Human Rights Watch. “Israel cannot treat northern Gaza as a free-fire zone. Those who do not flee retain the protections of international humanitarian law against indiscriminate, unlawful attacks.”
In a video posted by the Gaza Health Ministry, and verified by Storyful, a man is shown carrying a small body in a white shroud. He says it is his nephew, killed in an airstrike outside al-Shifa Hospital. He then lays him down gently alongside others in the baking sun.
“The children, the displaced who thought that these hospitals were safe places — and they were bombed,” the cameraman says as the sound of an Israeli warplane buzzes overhead.
Late Friday, most communication with al-Shifa and another hospital in Gaza City, al-Quds, appeared to have been cut off. “I am not getting anything from the doctors at the hospital,” said Medhat Abbas, director of the Gaza Health Ministry.
Kelly and Brown reported from Washington and Birnbaum reported from New Delhi. Miriam Berger, Claire Parker and William Booth in Jerusalem, Sarah Dadouch in Beirut, and Karen DeYoung in Washington contributed to this report.