Shattered and twisted ambulances and fire trucks are not a rare sight these days in Lebanon’s south. Amid months of intense aerial bombardment by Israel across the country, hundreds of medics and first responders were killed in attacks, leading to human rights organisations calling for war crimes investigations.
While medics and sites were targeted directly, others suffered from being close to sites that were hit. Medics say damage to healthcare facilities causes suffering twice – once at the time of the attack and another time in the weeks or months afterwards when those who need healthcare cannot access it.
A ceasefire between Israel and Hizbullah came into force in late November. In the following months, The Irish Times travelled with two international NGOs – Premiere Urgence Internationale (PUI) in mid-December and Médecins Sans Frontières (MSF) late last month – to visit affected sites in four locations, assessing damage and hearing about the experiences of medics during the war and after the ceasefire.
Lebanon’s ministry of health says that – from October 8th, 2023, to late November last year – Israeli forces attacked 67 hospitals, 56 primary healthcare centres and 238 emergency medical teams. At least 222 medical and emergency relief workers were killed, their figures show. The Lebanese health ministry did not respond to requests for an interview.
One of the deadliest days was October 3rd last year when, the World Health Organisation’s (WHO) director general said, 28 on-duty medics were killed in 24 hours. Last November the WHO said more healthcare workers and patients in Lebanon had been killed proportionally than in Gaza, Ukraine or any other active conflict.
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Medics in Lebanon repeatedly said they were worried about the country becoming a new Gaza. Last year, a United Nations commission of inquiry report found Israel has “implemented a concerted policy to destroy the healthcare system of Gaza”, saying its security forces “have deliberately killed, wounded, arrested, detained, mistreated and tortured medical personnel and targeted medical vehicles, constituting the war crimes of wilful killing and mistreatment, and the crime against humanity of extermination” – actions it called “collective punishment”.
Last October Human Rights Watch called on the UN to establish an international investigation into the attacks in Lebanon, and for Israel’s allies to suspend arms sales. In early March, Amnesty International said Israeli attacks on healthcare providers in Lebanon must be investigated as war crimes.
International law protects healthcare workers regardless of their affiliation: they only risk losing this protection if they are being used “outside their humanitarian function, to commit acts harmful to the enemy” – such as transporting ammunition or healthy fighters in service. Many Israeli attacks targeted the Islamic Health Association, a civilian institution affiliated with Hizbullah (Hizbullah is a social movement and political party, as well as a militant group).
Israeli officials and military spokespersons have accused Hizbullah of hiding rockets and missiles in hospitals – charges similar to those Israel makes about Gaza and the occupied West Bank – and accused Hizbullah and the allied Amal Movement of using ambulances to transport “terrorists” and weapons.
An Israel Defense Forces (IDF) spokesperson said it hit “military targets”, which are “subject to relevant provisions of international humanitarian law, including the taking of feasible precautions to mitigate civilian casualties”.
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The spokesperson said the IDF recognises “the importance of the special protections given to medical teams under international humanitarian law” and takes “action to prevent harm to them”, but accused Hizbullah of embedding “in civilian infrastructure” and “strategically place[ing] its military assets in proximity to medical facilities, such as hospitals and clinics, as part of its strategy”.
Operations are “planned based on extensive [intelligence] gathering and in accordance with international law. We have significant knowledge regarding the locations and methods in which the organisation hides weapons and infrastructure, and the forces are responding accordingly.”
Israeli forces were also previously asked by The Irish Times about their alleged use of so-called “double tap” strikes, but did not respond. This refers to a second air strike, sometimes landing after a rescue response has been launched. They are generally considered illegal under international law. The Irish Times has spoken to multiple medics and first responders in Lebanon who have alleged that these happened many times during the war.
Sarafand
Hanan Assi (50) ended up as the only healthcare worker in the Serepta primary health centre in Sarafand town for periods during the war. “I felt I had a duty to support and serve the people who remained.” She said there were 12 strikes in Sarafand on the first day of the escalation, and seven on the last day, before the ceasefire. “The drones were walking with me to [the centre] and the air strikes were accompanying me back home,” she said.
Many of the roughly 8,500 people who remained in the town could not afford to leave, she said. Monthly consultations went from about 1,000 to 200, while about 560 people collected medication.
Assi said she also did about 24 home visits across two months, including visiting elderly people such as a 75-year-old with pneumonia. She used her phone to ask a remote physician for guidance. Assi drove her own car, feeling that it was safer than ambulances, which she believed were being targeted. “I was afraid being associated with a medical team would put me more in danger.”
Glass shards still littered the car park of her medical centre in December; the broken back windows looked out on a destroyed building. Shards of glass were being loaded on to a truck outside. A poster said the centre had been funded by the European Union.
Dr Ali Kharroubi (41) said more than half of patients with chronic illnesses had neglected their care during the war “because of depression, they were thinking ‘I will die’.”
Assi recalled her own mental state declining. “At the beginning I was very courageous, I was motivated ... but during the last few weeks I got very tired, even psychologically, and started using antidepressants. Until now I’m still not understanding what actually happened. I lost my energy.”
Tyre
Two days before Israel’s aerial assault escalated across Lebanon, five babies who were delivered in Tyre’s Jabal Amel Hospital needed intensive care, director Wael Mroueh (49) said. The newborns ended up staying for three weeks, amid the bombardment, before they could be transferred.
At the same time, the hospital became a shelter for staff. Mroueh said out of 350 staff, between 100 and 120 remained with their families, leaving roughly 80 beds free for patients. Only about 2,000 people stayed in the city in total, he estimated, but the hospital “had many air strike victims and treated them”.
Mroueh – whose own home was damaged by an air strike – said drivers were forced to travel 40km north, to the city of Saida, to get food, medication and other supplies – a dangerous journey given that Israeli drones were known to target vehicles on the roads.
“I will never forget the staff who remained during the war,” Mroueh said. He arranged for ping pong and backgammon tables and playing cards to be available “for relief for the staff”. He warned them not to move around. Three staff members who fled Tyre with their families were killed, he said.
Close to the end of the war, an Israeli warning came through that an air strike would hit close to the hospital itself. Mroueh said he made calls to the International Committee of the Red Cross (ICRC) and the strike never came.
Qana
A dog sat outside the governmental hospital in Qana, a village 12km southwest of Tyre. The animal is famous, staff explained: it led rescuers to its wounded caregiver following an air strike – the caregiver died and the dog stayed with them since.
“I witnessed very dark and horrible cases,” said a security guard, who gave his name as Abu Hadi. “You cannot even have time and opportunity to sleep because of all the rockets. I saw so many dead. I know everything, every detail in this building. I felt like I was responsible so I had to stay to ensure the electricity, water was available and it was very risky to leave.”
Abu Hadi took care of seven dogs and as many as 45 stray cats during the height of the war.
Upstairs, newly returned hospital director Mohammad Dakhlalleh (45) was sitting in his office – the window of which was broken by the force of an air strike.
“One big strike was at the entrance of hospital. Another big strike blocked the roads nearby. The ambulances couldn’t reach the hospital here.”
Dakhlalleh left Qana with his young children following the escalation of conflict last September, but about 10 other staff stayed, including the emergency room director. They struggled, in particular, from not having an operating room, though they managed to establish one after a while – a physician and medical engineer performed 17 surgeries during the war. Transferring patients was dangerous and it was difficult to follow up with them due to “communication” problems, Dakhlalleh said.
The hospital did not have any equipment to scan for head injuries. They also lost electricity after a generator went out of service – a cable put in to supply a new source was cut by another air strike.
The pharmacy stayed open. The nurse responsible for dispensing medications, who just gave his first name, Mahmoud, said he injured his shoulder from the pressure of a strike which landed while he was at work.
In December, Dakhlalleh said, Qana’s hospital was still giving back dead bodies to bereaved families, while other corpses were still being found under the rubble. Meanwhile, hospital staff were concerned that part of their roof might fall down.
Bint Jbeil
“To say that there is a functional and running healthcare system in southern Lebanon would be an overstatement,” said medical director Ali Hassan Abbas, who had earlier shown a video on his phone of Israeli soldiers drinking coffee in his own kitchen, when they occupied it during the war.
The town of Bint Jbeil – about 4km from the Israeli border – was traditionally known as the “capital of resistance”. Abbas said a lot of staff escaped following a strike very close to Bint Jbeil government hospital on the first day of the escalation. In the following weeks there was a direct hit within the compound of the nearby Salah Ghandour Hospital, with the IDF saying there was a “command centre” within a mosque there.
“This entire area lost its access to healthcare,” Abbas said. “To say it was immense suffering would be an understatement.”
He said displaced patients with kidney problems or cancer were cut off from services. “You could die trying to reach this treatment.”
Abbas said a lot of the hospital’s equipment was damaged: for example, they have no working X-ray machine. Staff came in December to assess the damage, renovation began in January, and some patients were seen from February. “We’re renovating step by step. We’re getting electricity back: now we’re on the public grid again. Kidney dialysis will start again [soon], lab tests are working again. Radiology department and ER are working, but we have no in-patients, we don’t have functional wards.” Shattered glass had been replaced by Plexiglas or plastic sheeting.
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Hospital director Lina Bazzi said the damage has been estimated as high as $300,000 (€278,000).
She recalled the nursing team and other staff coming in with broomsticks to clean up. She walked up to the roof, where more than 150 solar panels are non-functional due to the impact of shrapnel, and the damaged ceiling now lets in rain.
In the intensive care unit on the second floor, patient information cards were scattered on the ground and an alarm was constantly ringing. “We can’t get it to stop,” she said. The neonatal ICU was not operating as “there’s not a window or a door”.
She said two dialysis machines weren’t working and cling film covered the windows, even though dialysis patients are at risk of hypothermia.
The operating room was contaminated by dust. “We can’t operate now because we have no ability to keep patients for post-operative care,” she said. Patients needed to be lifted up the stairs because the elevators were not functioning.
Her own office had its ceiling half-caving in. “I’ll be okay as long as there’s no air strike or earthquake,” she said jokingly.
Shaqra
Medical organisations are struggling to find solutions. In the village of Shaqra, about 109km south of Beirut, Médecins Sans Frontières set up a temporary “mobile clinic” in late February. A team were doing consultations in a municipality building, across the road from another destroyed building.
Present were a nurse, a “health promoter”, a doctor and psychologist. Before visiting, they sent out alerts to WhatsApp groups. They carried out referrals or treated people for a range of needs including diabetes, hypertension, and infections from the water systems being damaged when they returned home. The medics said they still had no accurate idea of how many medical facilities were functioning in the wider area and what their capacities were.
Psychologist Jana Lawant said people who came to them could not always recognise that many symptoms they were facing might be psychological and caused by the stress of the war: displacement; bereavement; destruction of their homes and livelihoods. Complaints included lack of sleep; lack of energy; unexplained pains; digestive issues; involuntary urination in children; vomiting – for instance – when Israeli drones were flying nearby.
People are “unable to move on and heal because the incidents are still happening ... they’re still inside the trauma, they’re still facing a lack of safety,” she said.
Reconstruction
Kevin Charbel, PUI’s head of mission for Lebanon, said “a large amount of health infrastructure ... has been destroyed”. This means the mass return of displaced civilians has been dangerous because “the infrastructure for public health in particular is not there any more”. Their disconnection to usual care also means a higher level of referrals to hospital now for Lebanese people with chronic illnesses, among other new challenges.
A push for a state-level rehabilitation response has been complicated by uncertainty about whether the ceasefire will hold. While Israel was supposed to leave Lebanese territory completely by an extended deadline of February 18th, it has retained a presence in five “strategic” locations and continues to carry out attacks on what it says are Hizbullah targets.
Israeli drones are regularly heard in southern Lebanon in a violation of Lebanese airspace. There was another escalation this month after Israel said it had intercepted rockets fired from southern Lebanon into Israel – which Hizbullah denied responsibility for – and reacted with multiple waves of retaliatory attacks.
“We kind of have a dilemma,” Charbel said. “Try to fix a minimum of basic services, while knowing the Israelis could easily just destroy it again, or don’t fix it, and watch on as we see the displaced struggle immensely to get back home.”
For now, he sees smaller jobs as being worth it, such fixing windows, but larger work might have to wait until a more certain peace has been sustained.
PUI itself is not initiating any major reconstruction, “but we ready have plans drawn up to rebuild health centres in areas heavily affected by the conflict,” he said. “If things stay stable enough, we’ll start the work around June.”
