• health policy
• public health

On 28 February 2019, an independent international commission formed by the United Nations Human Rights Council (UNHRC) submitted the findings of a report investigating concerns for violations of international and human rights laws as a result of the Great March of Return protests in the Gaza Strip.1 The protests, commencing on 30 March 2018 and continuing every Friday until this day, seek to highlight the right of return for Palestinian refugees to villages and towns inside what is now Israel as outlined in UN resolution 194 and lifting of the 12-year blockade on the Strip. Weekly protests at the Israeli-Gaza fence started on Land Day, which commemorates the 1976 killing of six unarmed Palestinians during protests against land expropriation in the Galilee.2

As documented in this report, the response to the Great March of Return protests have generated another source of humanitarian emergency in Gaza. Since the start of demonstrations, the number of casualties is staggering. 277 Palestinians have been killed—including 41 children—and 31 214 have been injured, 16 556 of whom required hospital transfer and treatment. Of those patients, 3310 were children.3

Limb injuries secondary to Israeli security forces high-velocity, close range weaponry fire condemn a new generation of Palestinians to life with disability in a population already suffering from high rates of extremity injuries and amputations from previous wars.4–6 Of the 6846 live ammunition casualties since 30 March, 5784 have involved the limbs.3 In April 2018, Medicins Sans Frontieres (MSF) noted the ‘devastating [limb] injuries of unusual severity, which are extremely complex to treat’.7 The numbers attest to this—128 patients have required amputations while at least 700 patients will require long-term limb reconstruction, requiring multiple surgeries and years of rehabilitiation.3 8 9 The complexity and volume of injuries, MSF noted recently, would ‘…overstretch the best healthcare systems in the world’.10 Israel has boasted of the intentionality to maim or kill behind every shot fired,11 which is in line with their policy of deliberately disabling youth in West Bank refugee camps.12

Complicating the ability to effectively care for casualties, and a key component of the report’s concerns for crimes against humanity committed against Palestinian protesters, has been the Israel security force’s targeting of health professionals. As of December 2018, three health providers have been killed and 560 injured during attacks on healthcare workers and facilities.8 13 These numbers are especially sobering in light of Israel’s admission that ‘everything was accurate and measured, and we know where every bullet landed’.11 In a highly publicised case, 21-year-old Palestinian Medic, Ms Razan Al-Najjar, was killed while donning a whitecoat and providing medical first aid to wounded demonstrators.14 The month prior to her death, she had been interviewed by the New York Times as one of the only female volunteer first responders at the protests.15 A recent New York Times investigation into the killing revealed that Ms Al-Najjar was more than 100 yards away from the border fence, in a group that posed no imminent threat and included eight medics when she was shot and killed.16 In a separate incident, a Canadian physician sustained bilateral lower leg injuries while standing near a clearly marked medical tent. Approximately 1 hour later, the Palestinian first responder who treated the Canadian physician’s leg injuries was killed while providing care to another wounded patient near the fence.17

Despite UNHRC’s independent commission report noting that Israeli security forces violations may constitute crimes against humanity for targeting and killing Palestinian protesters posing no imminent threat of death or serious injury to others, including children, journalists, disabled people and health workers,1 attacks on Palestinians continue while the international community fails to develop a coherent or meaningful response to this use of deadly force. We are disappointed by the silence of national and international medical associations worldwide. Such inaction makes the global health community complicit in a preventable injustice that will have long lasting public-health consequences not only for Gaza, but for the entire region, as stated by The Lancet following the attacks on Gaza in 2009.18 Without intervention to address the blockade on Gaza, the downstream effects of military occupation on the territory, and the worsening humanitarian crisis in the Strip, patients with physical and mental trauma will continue to flood an already overwhelmed Gazan healthcare system.