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By John Spencer
chair of urban warfare studies at the Modern War Institute (MWI) at West Point; served for 25 years as an infantry soldier and two tours in Iraq
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As a basic principle of the international law of armed conflict—as well as basic humanity—attacks against civilian sites are prohibited, unless, for example, those civilian sites are used for military purposes. On top of the standard protection of civilian objects, hospitals have a special level of protection under international law, given that they are places of sanctuary. Those in need of medical attention should be able to receive it without fear or danger.
That is also why international law specifically requires that hospitals not be used to shield military objectives from attack, for example, if a hospital is used for "interference, direct or indirect, in military operations, such as the use of a hospital as a shelter for able-bodied combatants or fugitives, as an arms or ammunition store, as a military observation post, or as a center for liaison with combat forces," per the U.S. Department of Defense law of war manual. Such uses can lead to a hospital losing its protected status.
If a hospital is being used for military purposes it does not mean the patients and staff inside the hospital automatically lose their civilian status. The medical staff, transportation, and wounded inside them remain protected. Even if a hospital is being used for acts harmful to the enemy, the response must follow all the laws of armed conflict—including proportionality and taking feasible precautions to mitigate civilian harm.
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The law also requires that the attacking force give advance warning and time for the party to stop using the hospital. But if a force is coming under fire from a hospital, the defending force may respond without having to provide advance warning.
Because of all the special protections surrounding hospitals, they have alarmingly and increasingly been used for military purposes by combatants such as Al-Qaeda in Iraq (AQI), Islamic State of Iraq and Syria (ISIS), and especially Hamas, who historically do not follow the laws of war and intentionally shield themselves behind protected objects and groups.
As a result, the United States and many other countries have recently had to conduct operations against enemy forces in hospitals.
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In April 2003, an American soldier, Private First Class Jessica Lynch, was being held captive in a hospital in Nasiriyah, Iraq. There were also reports that the hospital was being used as an enemy command-and-control facility. The U.S. military conducted a hostage rescue raid to retrieve her. The soldiers also recovered the bodies of 11 U.S. Army soldiers, an enemy weapons cache, and intelligence from the enemy planning center in the basement of the hospital.
Similarly, in the November 2004 Second Battle of Fallujah, the U.S. military and Iraqi forces made the assault of the city's main hospital, Fallujah General Hospital, a preliminary objective in the battle's opening moments. The attack included breaching the hospital and engaging the insurgents inside. The operation was conducted to remove the enemy forces in it, but more importantly, to prevent the hospital from being used as a propaganda tool. The hospital was one of the reasons for the U.S. military's failure in the first battle of Fallujah in April 2004, when the hospital was used by insurgents, through international media, to present inflated civilian casualty figures and a perception of indiscriminate force being used by the U.S. military. Those reports caused political instability in the newly formed Iraqi government and international coalition.
In December 2016, during the 2016-17 Battle of Mosul, Iraqi Security Forces (ISF) launched an armored division raid against Mosul's As Salam hospital in Eastern Mosul, because ISIS was using it as their "tactical center of gravity." The hospital was the scene of a horrific back and forth battle that included an airstrike inside the hospital complex conduct by U.S. led coalition warplanes. In June 2017, the ISF assaulted the Al Jamouri Hospital Complex in Western Mosul. Another massive battle ensued, and multiple airstrikes reduced much of the complex to rubble. The operation included the coalition firing white phosphorous artillery shells near the hospital complex to provide the ISF concealment smoke from ISIS snipers inside the hospital.
And yet, the U.S. encountered only sporadic use of hospitals in Afghanistan and Iraq. That does not appear to be the case in Gaza, where in almost every hospital the IDF has arrived at, it has uncovered and published military use by Hamas.
The terrorist group purposefully and systematically developed a strategy to use Gaza's hospitals for military purposes. Hamas knows the laws of war, it knows the public sensitivity, and it exploits those to both hamper the IDF's actions and invite international condemnation.
In Gaza's largest medical complex, the Al-Shifa hospital, the IDF found evidence that hostages were held there. They also found Hamas military weapons, ammunition, and equipment in many of the buildings in the complex. Most concerning was the presence of a large Hamas tunnel with a full command and control architecture utilizing the hospital's power sources that had been constructed purposely under the hospital grounds.
Meanwhile, Hamas was filmed firing at the IDF from within Sheikh Hamad Hospital. More Hamas militants fired a rocket-propelled grenade in front of the Al-Quds Hospital, then immediately ran inside.
The IDF found vehicles used in the October 7 massacre and a Hamas-built tunnel under the Indonesian Hospital. Weapons, ammunition, equipment, another tunnel, and evidence of hostages were found in the Al-Rantisi Hospital. Weapons hidden in incubators and evidence of a Hamas command center and base were found at the Kamal Adwan Hospital.
Most recently, the IDF found over 20 Hamas combatants who had taken part in the October 7 attacks hiding inside of the Al-Nasser Hospital in Southern Gaza. They also found vehicles used in the attack, Hamas weapons, and evidence that Israeli hostages had been held there.
To date, Israel has followed the rules when interacting with hospitals. It has provided warning before acting against hospitals suspected of Hamas use. And it has gone beyond the requirements of the law. It has facilitated evacuation, provided its own supplies to those present in the hospital, and helped provide alternative medical facilities until the ones being searched can restore full activities.
Perhaps most importantly, it appears that Israel has refrained so far from attacking hospitals from the air, even where it would be lawful to do so.
Instead, the IDF has sent in ground forces to search and destroy military infrastructure inside hospitals and detain terrorists hiding in them. It has sent doctors, Arabic speakers, and other specially trained staff to assist hospital staff and patients while the IDF is present. And it has left hospitals as quickly as possible, allowing them to resume full operations.
The fact that the International Committee of the Red Cross, World Health Organization, and United Nations have made public statements condemning Israel for searching hospitals, and never condemn Hamas for using the hospitals in the first place, is telling. During the war, and even more importantly, before the war, these organizations could have focused their efforts on stopping Hamas from exploiting hospitals and putting staff and patients in danger. Doing so would not only avoid the need for the IDF to operate within and near hospitals but would also send a message to all terrorist organizations that the world will not accept them putting in danger the very people who most need protection.
There is real danger in not condemning those who use hospitals for military purposes. It gives the world the perception that hospitals are completely immune to military action, which sends a message to all terrorists that the use of hospitals is an effective, albeit illegal, military strategy.
John Spencer is chair of urban warfare studies at the Modern War Institute (MWI) at West Point, codirector of MWI's Urban Warfare Project and host of the "Urban Warfare Project Podcast." He served for 25 years as an infantry soldier, which included two combat tours in Iraq. He is the author of the bookConnected Soldiers: Life, Leadership, and Social Connection in Modern Warand co-author ofUnderstanding Urban Warfare.
The views expressed in this article are the writer's own.
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