Reinvigorating Proportionality to Protect Hospitals During War

The Growing Crisis: Attacks on Healthcare in Conflict Zones

Over the past five years, attacks on healthcare facilities and personnel in armed conflict have tripled, with Myanmar, Gaza, Sudan, and Ukraine experiencing the most incidents. These attacks inflict massive harm, extending beyond immediate deaths and injuries to disrupt essential medical services and exacerbate existing health crises.

The Erosion of Protected Status

Despite international humanitarian law explicitly protecting hospitals and medical facilities, these protections are increasingly disregarded. Perpetrators are justifying attacks by claiming facilities are being used for activities “harmful to the enemy,” such as storing weapons or housing fighters. This justification, while sometimes backed by claims of evidence, often remains contested and doesn’t negate the protections afforded to patients and staff.

Gaza: A Case Study in Disputed Justifications

The war in Gaza, beginning in 2023, has seen over 400 incidents of violence damaging health facilities as of October 2025, with a third resulting from Israeli Defense Forces (IDF) airstrikes. Thirty-four of Gaza’s 36 hospitals have sustained damage. The IDF has frequently justified these attacks based on allegations of Hamas using hospitals for military operations – claims supported at times by the Pentagon, but contested by hospital administrators, medical volunteers, and UN human rights investigators. Evidence suggests Hamas has conducted interrogations in Al-Shifa Hospital and established tunnel networks under or near some hospitals.

The Warning Requirement: A Largely Ineffective Safeguard

International law mandates a warning be issued before attacking a hospital suspected of military utilize, allowing time to cease harmful activities. However, this warning requirement is largely ineffective. Warnings are rarely given, and even when issued, attacks are not delayed to allow for a response. This failure to adhere to established protocols exacerbates the harm to vulnerable populations.

Proportionality: A Critical, Often Overlooked, Principle

The principle of proportionality – prohibiting attacks expected to cause excessive civilian harm in relation to the anticipated military advantage – offers a crucial safeguard. However, it’s often overlooked in military messaging defending attacks on hospitals. A rigorous assessment of proportionality, considering both immediate and potential long-term consequences, could prevent many brutal attacks.

Assessing Proportionality in Practice

Applying proportionality requires careful consideration of several factors. The special protections afforded to the wounded and sick, the potential for disrupting essential hospital functions, and the vulnerability of patients and staff all weigh heavily in the assessment. Attacks should be limited in scope and intensity, avoiding the use of highly explosive weapons. Precautions, such as maintaining essential services like electricity and water, are also vital.

In Gaza, evidence suggests the IDF has not consistently applied proportionality assessments, employing explosive weapons in situations where the expected harm to civilians outweighed the military advantage gained. The destruction of key hospital functions, the disruption of medical care, and the resulting exacerbation of health conditions all point to a failure to adequately consider the proportionality principle.

The Importance of Concrete and Direct Military Advantage

Some militaries have erroneously broadened the definition of “military advantage” to include any step toward achieving overall war goals, rather than a “concrete and direct” advantage in the specific operation. This diluted interpretation undermines the proportionality rule and increases the risk of excessive civilian harm.

Future Trends and Challenges

The trend of attacks on healthcare is unlikely to abate without significant changes in international norms and enforcement mechanisms. Several factors contribute to this concerning outlook:

• Geopolitical Tensions: Intensified geopolitical competition diminishes the prospects for sustainable peace processes and increases the likelihood of armed conflict.
• Urban Warfare: Increasingly, conflicts are taking place in densely populated urban areas, placing healthcare facilities directly in the line of fire.
• Erosion of International Law: A growing disregard for international humanitarian law weakens the protections afforded to civilians and essential infrastructure.
• Information Warfare: Disinformation and contested narratives surrounding the use of hospitals by armed groups complicate proportionality assessments and justify attacks.

The Role of Technology and Data

Advances in data collection and analysis could play a crucial role in monitoring attacks on healthcare and holding perpetrators accountable. Improved satellite imagery, open-source intelligence, and data-driven investigations can provide evidence of violations and support advocacy efforts.

FAQ

Q: What is the legal basis for protecting hospitals in armed conflict?
A: International humanitarian law, specifically the Geneva Conventions, provides explicit protections for hospitals and medical facilities.

Q: What constitutes a legitimate military target within a hospital?
A: Only parts of a hospital actively used for acts harmful to the enemy are legitimate military targets, and even then, attacks must adhere to the principles of proportionality and precaution.

Q: What is the principle of proportionality?
A: It prohibits attacks expected to cause excessive civilian harm in relation to the anticipated military advantage.

Q: What can be done to improve the protection of healthcare in conflict zones?
A: Strengthening adherence to international law, improving data collection and analysis, and promoting accountability for violations are crucial steps.

Did you recognize? The ICRC, in conjunction with 29 state militaries, has offered practical measures to meet the precautions requirement in connection with healthcare facilities.

Pro Tip: Understanding the nuances of international humanitarian law is essential for journalists, policymakers, and anyone concerned with protecting civilians in armed conflict.

Learn more about the challenges facing healthcare in conflict zones and explore resources from organizations like the International Committee of the Red Cross (ICRC) and the World Health Organization (WHO). Share this article to raise awareness and advocate for the protection of healthcare workers and facilities.