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Asi et al. Conict and Health (2024) 18:24
https://doi.org/10.1186/s13031-024-00580-x Conict and Health
†Yara Asi and David Mills are co-rst authors.
†Bram Wispelwey and Weeam Hammoudeh are co-senior authors.
*Correspondence:
David Mills
davidmills@hsph.harvard.edu
Full list of author information is available at the end of the article
Abstract
Background Since the Hamas attacks in Israel on 7 October 2023, the Israeli military has launched an assault in
the Gaza Strip, which included over 12,000 targets struck and over 25,000 tons of incendiary munitions used by 2
November 2023. The objectives of this study include: (1)the descriptive and inferential spatial analysis of damage
to critical civilian infrastructure (health, education, and water facilities) across the Gaza Strip during the rst phase of
the military campaign, dened as 7 October to 22 November 2023 and(2) the analysis of damage clustering around
critical civilian infrastructure to explore broader questions about Israel’s adherence to International Humanitarian
Law(IHL).
Methods We applied multi-temporal coherent change detection on Copernicus Sentinel 1-A Synthetic Aperture
Radar (SAR) imagery to detect signals indicative of damage to the built environment through 22 November 2023.
Specic locations of health, education, and water facilities were delineated using open-source building footprint and
cross-checked with geocoded data from OCHA, OpenStreetMap, and Humanitarian OpenStreetMap Team. We then
assessed the retrieval of damage at and with close proximity to sites of health, education, and water infrastructure
in addition to designated evacuation corridors and civilian protection zones. The Global Moran’s I autocorrelation
inference statistic was used to determine whether health, education, and water facility infrastructure damage was
spatially random or clustered.
‘Nowhere and no one is safe’: spatial analysis
of damage to critical civilian infrastructure
in the Gaza Strip during the rst phase of the
Israeli military campaign, 7 October to 22
November 2023
YaraAsi1,2†, DavidMills1,3*†, P. GreggGreenough4,5, DennisKunicho1, SairaKhan4, Jamon Van DenHoek6,
CoreyScher7, SaleemHalabi, SawsanAbdulrahim1,8, NadineBahour1, A. KayumAhmed1,9, BramWispelwey1,5† and
WeeamHammoudeh1,10†
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Asi et al. Conict and Health (2024) 18:24
Background
e Gaza Strip is a small coastal enclave with the Medi-
terranean Sea to the west, Egypt to the south, and Israel
to the north and east, although it has no legally dened
borders. It is part of the occupied Palestinian territory
(oPt), along with the West Bank and East Jerusalem,
to which it is not geographically connected. Home to
approximately 2.2million people as of 2022 [1], the Gaza
Strip is commonly recognized as one of the most densely
populated places in the world (approximately 15,000 per-
sons/sq mile) [2].
On 7 October 2023, Hamas militants launched an
attack inside Israel killing approximately 1200 people
and taking 240 hostages [3]. Almost immediately, Israel
launched a wide-scale military campaign on the Gaza
Strip and instituted a complete siege on all its land
borders. At the time of writing, in late February 2024,
Israel’s military campaign has killed more than 29,000
people in the Gaza Strip, around 70% of whom are esti-
mated to be women and children [4]. e rst 46 days
included an unprecedented civilian death toll, eclipsing
the total number of Ukrainian civilian deaths in the rst
21 months of the Russia-Ukraine War that began in 2022
[5].
e Gaza Strip has experienced four other massive
Israeli military assaults over the past 15 years. In each
instance, widespread damage to homes, businesses, util-
ity infrastructure, and educational and health facilities
has been documented, leading to warnings of potential
violations of the laws of war by Israel [6–9]. In the rst
month of the current military campaign, over 25,000 tons
of incendiary munitions have been red into the Gaza
Strip [10], including two 900-kilogram bombs on the
densely populated Jabalia refugee camp on 31 October
2023 [11]. e Israeli military struck over 12,000 targets
with extensive human consequences. By the end of 2023,
over 1.9 million Palestinians in Gaza (85% of the total
population) had been internally displaced due to bomb-
ing and evacuation orders [12].
Since the outset of the 2023 military campaign, there
has been regular reporting and subsequent international
condemnation of the widespread damage and destruc-
tion of infrastructure throughout the Gaza Strip [13,
14]. Such incidents are especially concerning consider-
ing statements by several Israeli ocials that dehuman-
ize Palestinians, incite violence against them, or call for
their displacement [15]. e high death toll and level of
damage in the Gaza Strip have raised serious allegations
of the violation of International Humanitarian Law (IHL)
by the Israeli military; specically, whether Israel’s bomb-
ings “distinguish between the civilian population and
combatants, and between civilian objects and military
objectives” and if the “incidental harm on civilians is pro-
portional to the concrete and direct military advantage
anticipated.” [16] ese questions become especially rele-
vant when taken into account other Israeli actions during
this military campaign, including instituting a complete
siege of food, fuel, water, and medicine [17]; conducting
mass arrests of men and boys [18]; vocal campaigns by
Israeli politicians for resettlement of residents of Gaza
to other countries [19]; the massive forced displace-
ment from the north to the south of Gaza [20]; and other
actions that have been called war crimes by Human
Rights Watch [21], Amnesty International [22], and other
human rights groups [23].
IHL oers specic protections to civilian infrastruc-
ture, such as schools and hospitals. Parties to an armed
conict must at all times distinguish between civilians
and civilian objects on the one hand, and soldiers and
military objectives on the other. Direct or indiscriminate
attacks on civilians and civilian objects are prohibited.
A hospital or school may become a legitimate military
target only if it is both being used for specic military
operations of the enemy and also if its destruction oers
a dened military advantage. According to the Interna-
tional Committee of the Red Cross, “If there is any doubt,
they cannot be attacked.” [24].
When attacking a military objective, parties are obli-
gated to take all necessary precautions to avoid, or at
Results During the period under investigation, in the entire Gaza Strip, 60.8% (n = 59) of health, 68.2% (n = 324) of
education, and 42.1% (n = 64) of water facilities sustained infrastructure damage. Furthermore, 35.1% (n = 34) of health,
40.2% (n = 191) of education, and 36.8% (n = 56) of water facilities were functionally destroyed. Applying the Global
Moran’s I spatial inference statistic to facilities demonstrated a high degree of damage clustering for all three types of
critical civilian infrastructure, with Z-scores indicating < 1% likelihood of cluster damage occurring by random chance.
Conclusion Spatial statistical analysis suggests widespread damage to critical civilian infrastructure that should have
been provided protection under IHL. These ndings raise serious allegations about the violation of IHL, especially in
light of Israeli ocials’ statements explicitly inciting violence and displacement and multiple widely reported acts of
collective punishment.
Keywords Israel, Gaza Strip, Israel-Hamas war, Health, Education, Water, Civilian infrastructure, Humanitarian,
International Humanitarian Law, Spatial analysis
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Asi et al. Conict and Health (2024) 18:24
the very least, minimize, death and injury to civilians
and damage to civilian objects. Such precautions include
doing everything possible to verify that a target is a mili-
tary objective; selecting methods of attack that minimize
civilian harm; assessing whether an attack would be dis-
proportionate; giving eective advance warning; and can-
celing an attack if it becomes apparent that such an attack
would be unlawful.
is study provides a descriptive and inferential spa-
tial assessment of damage to critical civilian infrastruc-
ture across the Gaza Strip during the rst phase of the
military campaign, from 7 October to 22 November
2023, two days before the temporary ceasere went into
eect. e primary objective of the study is to describe
patterns of damaged infrastructure and the proximity to
critical civilian infrastructure, dened in this study as
hospitals and health centers (health facilities), universi-
ties and schools (education facilities), water storage and
access points (water facilities), and the designated evacu-
ation corridor. ese facilities were chosen because of
their clear status as critical civilian infrastructure that is
protected under IHL, as infrastructure required for the
ability to sustain life in parts of the Gaza Strip, and the
availability of geocoded data for these humanitarian sec-
tors. e secondary objective of the study is to utilize
spatial statistics to determine damage clustering in order
to explore broader questions about whether the war has
been waged in a way that adheres to IHL by oering pro-
tections to these civilian infrastructures.
Methods
is paper characterizes the damage of critical civilian
infrastructure across all ve governorates of the Gaza
Strip (Fig.1) and whether infrastructure damage occurs
in a spatially random pattern. e analyzed civilian infra-
structure includes facilities protected under IHL and are
dened specically in this study as health, education, and
water facilities. e analysis also explores the relation-
ship of infrastructure damage to areas designated as a
‘protected’ evacuation zone and evacuation corridor by
the Israeli military evacuation order given on 13 October
2023. is order, which forced the displacement of the
two northern Gaza Strip governorate populations south
via the Salah al-Din Street southwest vectored corridor,
past the Wadi Gaza demarcation line to the southern
three governorates (Fig.1), was in eect until 1 Decem-
ber 2023, encompassing the full period of our study.
is study incorporates satellite radar and other open-
source datasets to spatially analyze and characterize the
damage from the impact of the rst phase of the Israeli
military campaign on critical civilian infrastructure pro-
tected under IHL.
Satellite radar-based damage analysis
A map of structural damage through 22 November 2023
was made with open-access 10 m resolution European
Space Agency Copernicus Sentinel-1A Synthetic Aper-
ture Radar (SAR) data using a multi-temporal coherent
change detection approach [25]. Coherent change detec-
tion has wide uptake in satellite radar-based approaches
to map earthquake damage (e.g. NASA ARIA emergency
response data products), and rests on the measurement
of changes in coherence, which is the similarity between
phase components of interferometric radar waves col-
lected over dierent points in time [26]. Stable coher-
ence over time in a built-up environment like the Gaza
Strip suggests the persistent presence of a feature, such
as a building [27], while a large and persistent decrease
in coherence from one image date to the next suggests
structural damage or destruction [28, 29]. Native resolu-
tion Sentinel-1 data acquired in the interferometric-wide
swath mode have a spatial resolution of 5m by 20m in
range and azimuth (radar geometries), which, when pro-
jected onto a geospatial grid in ground range, results in a
10m pixel spacing product. To conduct time series anal-
ysis of coherence data from Sentinel-1, native resolution
data requires interferometric processing, which results in
a 40m pixel spacing grid for the coherence data used in
this study. Interferometric processing of Sentinel-1 data
was conducted using the Alaska Satellite Facility’s HyP3
cloud-based processing infrastructure [30].
To map locations of likely damage, a one-year baseline
period (2022 to 2023) was established to identify regions
with high magnitude and low variability of coherence
over time. Regions with sucient stability (high coher-
ence, low variability) during the baseline period were
identied, and changes in coherence were tracked after
7 October 2023. For every identied stable pixel in each
Sentinel-1 A radar image of the Gaza Strip acquired
thereafter, the change in coherence was measured rela-
tive to the baseline coherence and locations of statisti-
cally signicant decreases in coherence were recorded as
likely damage. Using this approach, a map of cumulative
likely damage through 22 November 2023 was produced.
e area of damage was recorded for all building foot-
prints documented in the Microsoft building footprints
or OpenStreetMap (OSM) datasets (Table1). e result-
ing structure-level cumulative likely damage estimates
form the basis for our damage assessments described
below. (Since ground truth validation data were not
available to conrm the presence of structural damage
indicated by satellite radar analysis and thus precludes
quantication of damage accuracy, the study’s authors
found a moderately high agreement with a damage map
produced by UNOSAT [31]. Using a total likely damage
map across the Gaza Strip based on radar data acquired
through 5 November 2023, we were able to detect 68% of
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Asi et al. Conict and Health (2024) 18:24
Fig. 1 Map of the Gaza Strip outlining ve governorates, the Wadi Gaza evacuation zone line, and the Salah al-Din Street evacuation corridor
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Page 5 of 13
Asi et al. Conict and Health (2024) 18:24
building damage locations reported by UNOSAT based
on analysis of very-high resolution 30 cm WorldView-3
commercial satellite imagery collected on 7 November
2023. (is level of agreement is especially notable given
that our analysis is based on 10-meter resolution data).
Spatial analysis of damage of health, education, and water
facilities infrastructure
Pre-7 October georeferenced datasets on health facilities,
education facilities, and water facilities were imported,
modied, and analyzed in ArcGIS Pro 3.2 (ESRI, Red-
lands, CA) and R. Point data on health facilities, which
included hospitals and all types of specialty clinics, were
from the UN Oce for the Coordination of Humanitar-
ian Aairs (OCHA); a georeferenced dataset capturing
education facilities, including kindergartens, schools,
colleges, and universities, was generated using point
data from OSM and Humanitarian OpenStreetMap
(HOTOSM) (Table1).
Georeferenced water facility point data was also from
HOTOSM. e research team generated polygons from
the imagery pixels to capture the entire footprint of the
educational facilities and health facilities based on the
imported point data. Conrmed with very high-resolu-
tion satellite imagery and OSM base map data, the result-
ing polygon dataset was reviewed for completeness and
redundancy against available data from HOTOSM, and
a 5-meter buer was generated across each health and
education facility polygon and water point to improve
precision and minimize georeferencing errors.
To capture the extent of damage to health, education,
and water facilities, the number of each type of facil-
ity polygon with a non-zero area of cumulative damage
was recorded. Next, 25-meter and 50-meter buers were
generated around these facility polygons as well as the
evacuation corridor to measure damage in immediate
proximity to health, education, and water facility poly-
gons. e widths of these buers were dened by the
lethality and blast radii of the predominant incendiary
weapons used by the Israeli military in the Gaza Strip:
the precision-guided MK-80 series, whose sizes range
between 120 and 1000kg [32] and 155mm surface artil-
lery shells. e 500kg MK-82, with 89kg of high explo-
sives, has a high velocity blast of 32 m diameter, with
peak overpressures extending to 31m radius (62m diam-
eter), collapsing most buildings, severely damaging heavy
concrete structures, injuring nearly everyone within that
diameter, and killing most [33]. e 155mm artillery
shells have a lethality radius of 50m and injury radius
of 150m [34]. We considered the 25 and 50m buers as
conservative estimates given that the fragmentation of
these weapons upon detonation can extend much fur-
ther than nominally reported, and that the US Oce of
the Director of National Intelligence (ODNI) Assessment
found 40–45% of the 29,000 air-to-ground munitions
Israel has dropped in the Gaza Strip have been unguided
and with less precise and less discriminate targeting
compared to precision-guided weapons [35] which theo-
retically have more civilian protecting capacity. We mea-
sured the area and calculated the percent of damage to
each of the health and education facility polygons and the
water point 5m buer polygons, and used the percent of
damage to create an indicator variable identifying facili-
ties with at least 50% of the polygons being damaged. A
50% area threshold was chosen based on military dam-
age assessment guidance that considers a building unus-
able and functionally destroyed once it has sustained 50%
structural damage [36].
e degree of spatial relatedness of structural damage
at infrastructure sites was also measured using Global
Moran’s I. Global Moran’s I is a statistical measure of
spatial autocorrelation, which describes whether a geo-
graphic pattern of interest, in this case, structural dam-
age at infrastructure locations, is spatially clustered,
randomly distributed, or dispersed [37]. Global Moran’s I
is calculated using the equation:
I=
N
Wi
jw
ij
(x
i
−¯x)(x
j
−¯x)
i(x
i−
¯x)2
where N is the number of observations at locations i and
j; x and
¯x
are the attribute values of interest (percent of
facility polygon damage) and their means, respectively;
wij is a matrix of spatial weights (the strengths of the
spatial relationships in the data set), and W is the sum
of all wij. Assuming a null hypothesis of spatial random-
ness (zero spatial autocorrelation), the expected value of
Global Moran’s I is:
Table 1 Data sources
Data Source Selection criteria
Footprints https://github.com/microsoft/GlobalMLBuildingFootprints
https://openstreetmap.org
NA
Health https://data.humdata.org/dataset/state-of-palestine-health-0 Clinics and hospitals
Education https://data.humdata.org/dataset/state-of-palestine-schools
https://data.humdata.org/dataset/hotosm_pse_education_facilities
Kindergartens, schools, colleges,
and universities
Water https://data.humdata.org/dataset/hotosm_pse_points_of_interest Water distribution or storage sites
labeled as “water well”, “water tap”,
“drinking water”, and “water point”
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Asi et al. Conict and Health (2024) 18:24
E
(I)=
−1
N−1
Positive values for the Global Moran’s I associated with
statistically signicant p-values, dened as below a 0.05
threshold, suggest clustering patterns of infrastructural
damage and a rejection of spatial randomness (negligible
values) or dispersion (negative values). We measured
Global Moran’s I of damage at 25m buered infrastruc-
ture polygons, used inverse distance weighting, given by
1/d where d is the distance to i, to determine the inu-
ence of neighboring locations, Euclidean distance as the
measurement construct, and row standardization to min-
imize sampling design bias.
Results
Figure2; Table2 present the number and spatial distri-
bution of facility types stratied by governorate for the
analysis, and included 97 health facilities, 475 education
facilities, and 152 water facilities. e Gaza governorate,
which contains Gaza City, accounted for the largest num-
ber of health, education, and water facilities.
Table 2 Number of facility types and their distribution across Gaza Strip governorates
Facility Type Total (N) North Gaza Gaza Deir Al-Balah Khan Younis Rafah
Health facilities 97 17 (17.5%) 32 (33%) 18 (18.6%) 18 (18.6%) 12 (12.4%)
Education facilities 475 87 (18.3%) 199 (41.9%) 39 (8.2%) 85 (17.9%) 65 (13.7%)
Water facilities 152 33 (21.7%) 45 (29.6%) 21 (13.8%) 36 (23.7%) 17 (11.2%)
Fig. 2 Distribution of health, education, and water facilities infrastructure sites in the Gaza Strip
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Asi et al. Conict and Health (2024) 18:24
Infrastructure damage analysis
Our analysis shows that many health, education, and
water facilities are directly located or within close prox-
imity to areas of SAR-indicated damage. Damage was
detected at over 60% of all health facilities (60.8%, n = 59),
over two-thirds of education facilities (68.2%, n = 324),
and over 40% of all sites of water infrastructure (42.1%,
n = 64) (Table3). Considering the ‘functional destruction’
threshold where the area of damage is at least half of the
area of a facility polygon, we found that 35.1% (n = 34)
of health facilities, 40.2% (n = 191) of education facili-
ties, and 36.8% (n = 56) of water facilities were function-
ally destroyed (Table3). When assessed for proximity to
damage-aected areas, our analysis found evidence of
SAR-detected damage within 25 m of 70.1% (n = 68) of
health facilities, 75.8% (n = 360) of education facilities,
and 51.3% (n = 78) of water facilities in the Gaza Strip;
similarly, SAR-detected damage within 50m was found
for 78.4% (n = 76) of health facilities, 82.5% (n = 392) of
education facilities and 58.6% (n = 89) of water facilities.
Figure3 illustrates the cumulative burden of infrastruc-
ture damage across the Gaza Strip through 22 November
2023, and the spatial relationship of that infrastructure
damage to health, education, and water facilities. Fig-
ure 3 also outlines the designated evacuation corridor
and evacuation zone of the southern governorates. e
majority of the damage in this rst phase of the military
campaign took place in the northern two governorates
which contains Gaza City, the most populated city in the
Gaza Strip.
e degree of damage by governorate and facility type
is reported in Fig. 4. In North Gaza, 88.2% (n = 15) of
health facilities, 79.3% (n = 69) of education facilities, and
70% (n = 23) of water facilities sustained direct damage. In
the Gaza City governorate, 75% (n = 24) of health facili-
ties, 83.4% (n = 166) of education facilities, and 64.4%
(n = 29) of water facilities sustained direct damage. When
assessing facilities that were functionally destroyed,
57.1.% (n = 28) of health facilities, 58.4% (n = 167) of edu-
cation facilities, and 57.7% (n = 45) of water facilities in
North Gaza and Gaza City governorates met the 50%
or more damage threshold. In the three southern gover-
norates designated the evacuation zone below the Wadi
Gaza, 41.7% (n = 20) of the health facilities, 47.1% (n = 89)
of the education facilities, and 16.2% (n = 12 of the water
facilities had direct damage, and 12.5% (n = 6) of health
facilities, 12.7% (n = 24) of education facilities, and 14.9%
(n = 11) of water facilities were functionally destroyed.
Details for the counts and percentages of damaged facili-
ties at all three buer levels [0m, 25m, and 50m] and
counts stratied by the equal to or greater than 50% dam-
age threshold for each governorate can be found in Sup-
plemental Table 1.
e line representation of the Salah Al-Din Street evac-
uation corridor that we generated for this analysis was
46.8km in total length and was used to assess proxim-
ity to damage at the three buer levels (Table4). 2.1% of
the evacuation corridor intersected directly with damage.
is proportion of the evacuation corridor represents
1km of its total length. e evacuation corridor with the
50m buer intersected with damage at 11.6% of the road,
5km of its total length.
Spatial statistical analysis
Applying Global Moran’s I - a spatial inference statistic
to discern spatial heterogeneity - to the dataset of health,
education, and water facilities across the Gaza Strip, we
found a high degree of damage clustering for all three
types of critical civilian infrastructure, above and below
the 50% damage threshold (Table 5). For all the facili-
ties studied, Z-scores of these magnitudes indicate a < 1%
likelihood that this amount of clustering would occur
by random chance, regardless of the degree of damage.
is suggests that damage to these structures is highly
autocorrelated.
Discussion
e ndings from this study add to the evidence indicat-
ing that the level and scope of damage to critical civil-
ian infrastructure in the Gaza Strip from the rst phase
Table 3 Percent and counts of damaged facilities in the Gaza Strip by facility type, stratied by whether more or less than half of each
facility’s boundary intersected with SAR-detected damage
Total Facilities Damage
Buer level (meters) Facility Type NAny damage < 50% >=50%
0 Health facilities 97 59(60.8%) 25(25.8%) 34(35.1%)
25 68 (70.1%) 41 (42.3%) 27 (27.8%)
50 76 (78.4%) 49 (50.5%) 27 (27.8%)
0 Education facilities 475 324 (68.2%) 133 (28%) 191 (40.2%)
25 360(75.8%) 199(41.9%) 161(33.9%)
50 392 (82.5%) 243 (51.2%) 149 (31.4%)
0 Water facilities 152 64 (42.1%) 8 (5.3%) 56 (36.8%)
25 78 (51.3%) 17 (11.2%) 61 (40.1%)
50 89 (58.6%) 31 (20.4%) 58 (38.2%)
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Asi et al. Conict and Health (2024) 18:24
Fig. 3 Map of health, education, and water facilities overlaying cumulative damage, with an inset map in Gaza City, and the corresponding areas of dam-
age for each facility type within each radial buer across the Gaza Strip
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Page 9 of 13
Asi et al. Conict and Health (2024) 18:24
Fig. 4 Number of damaged facilities and percent damage to health, education, and water facilities by governorate and buered area
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Page 10 of 13
Asi et al. Conict and Health (2024) 18:24
of the Israeli military campaign between 7 October and
22 November 2023 has few, if any, precedents in recent
conicts. Within just 46 days, much of the critical civil-
ian infrastructure in the Gaza Strip was damaged or
destroyed. Direct damage of facilities across all Gaza
Strip governorates included over half of health and edu-
cation facilities and over a third of the water facilities. In
the North and Gaza governorates–the most populated
governorates in the Gaza Strip–over half of each facility
type was destroyed. Over a third of all health, education,
and water facilities across all governorates had equal to
or greater than 50% damage, by denition deeming them
completely destroyed [36].
Spatial analysis of this infrastructure damage (Table5)
demonstrates a lack of randomness and statistically sig-
nicant clustering of damage around critical civilian
infrastructure. Whereas negative Z-scores would sug-
gest avoidance of such infrastructure, positive Z-scores
of these magnitudes indicate a < 1% likelihood that this
amount of clustering would occur by random chance,
regardless of the degree of damage. e clustering of
damage detected at and adjacent to critical civilian infra-
structure described by this data demonstrates that not
only are these civilian sites not being aorded legal pro-
tections as mandated under IHL, but they are being con-
sistently damaged and destroyed, supporting claims that
“nowhere and no one is safe” in the Gaza Strip [38]. It is
important to note the time-limited period of this analy-
sis. Bombing continued after the temporary ceasere
ended at the end of November, and the ramications of
these additional attacks were not included in this analy-
sis, as this study focused on the period before the tempo-
rary ceasere.
is level of damage raises questions about whether
these areas of the Gaza Strip will be able to sustain civil-
ian life once the Israeli military campaign concludes,
even for those few whose homes may be left standing.
e critical civilian infrastructure necessary for life has
been destroyed in many parts of the northern Gaza Strip
and will require signicant investments in time and fund-
ing to be able to sustain communities again. Along with
the high civilian death toll [39], such damage has led to
the rapid deterioration of the living conditions for sur-
vivors of bombings, leaving them unable to access basic
services vital for the realization of the right to the highest
attainable standard of physical and mental health, well-
being, or even basic survival [40–42]. At least 1.3million
internally displaced people were sheltering in 155 United
Nations Relief and Works Agency sites by the end of the
rst stage of the military campaign, frequently within
health and education facilities [43, 44], meaning that
damage to these buildings represented direct threats to
sheltering civilians. e inability of international actors
to protect these facilities, despite the overwhelming
destruction, demonstrates the fundamental limitations
of IHL that should be seen as “intolerable, as states and
armed groups can use the fog of war and exibilities in
their targeting assessments to justify virtually any attack.”
[45].
While the data from this study cannot determine inten-
tionality, the strength of clustering suggests the possibil-
ity of direct attacks on critical civilian infrastructure as
part of a larger program of collective punishment, in line
with both the Israeli military’s denial of food, water, and
electricity to the population of the Gaza Strip and the lit-
any of ocial statements to this eect as noted above [21,
46]. Other considerations for direct attacks include Isra-
el’s assertions that some of these civilian objects, such as
hospitals, were used as military command centers. While
civilian objects may lose their protection from attack
only if they are being used outside their humanitarian
function, to commit acts “harmful to the enemy” [47],
parties must refrain from attacking a civilian object if it
would rstly, cause disproportionate harm to the civilian
population, or second, be carried out in a way that fails
to discriminate between combatants and civilians. Ulti-
mately, the possibility that all of the attacked sites justi-
ably lost their legal protections is unlikely given the lack
of evidence to date, and because the most robust claim to
this eect, that Gaza’s largest hospital was being used as
a military “command-and-control center”, has not been
proven; the purported evidence shared thus far falls far
short of Israel’s initial, and specic, claims that led to the
hospital being raided and attacked [48]. Independent and
transparent investigations are required to assess what this
data and other studies that have assessed damage to criti-
cal civilian infrastructure indicates about Israeli military
Table 4 Proximity of damage along the evacuation corridor of
Salah al-Din Street, 7 October to 22 November 2023
Salah al-Din Street
Buer level (meters) Percent damage
0 2.1%
25 8.4%
50 11.6%
Table 5 Spatial autocorrelation of infrastructure damage to
facilities in the Gaza Strip by facility type
Facility Type Global Moran’s I p-value Z-score
Health facilities
Any damage
>=50% damage
0.380895
0.348284
< 0.000001*
< 0.000001*
5.848462*
5.362817*
Education facilities
Any damage
>=50% damage
0.431564
0.342495
< 0.000001*
< 0.000001*
19.860574*
15.776496*
Water facilities
Any damage
>=50% damage
0.544802
0.519995
< 0.000001*
< 0.000001*
9.837989*
9.385527*
* statistically signicant
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 13
Asi et al. Conict and Health (2024) 18:24
intentions and practices, especially in light of the concern
of war crimes committed in previous attacks on the Gaza
Strip and the case of genocide brought before the Inter-
national Court of Justice by South Africa [6–8, 49].
Life-threatening conditions for mandatory evacuation
e Israeli evacuation orders for citizens living in the
northern governorates (North Gaza and Gaza) into the
governorates south of Wadi Gaza (Deir Al-Balah, Khan
Younis, and Rafah) on 13 October 2023 were immedi-
ately and widely protested by health and humanitarian
groups, with the World Health Organization calling them
a “death sentence” for patients [50]. Aside from having to
undertake the arduous journey, often made on foot with
families carrying whatever they could of their personal
belongings, evidence from this study suggests that the
route itself was not safe. Our analysis nds direct target-
ing of infrastructure along the corridor, indicating that,
despite its demarcation as an evacuation corridor, secu-
rity was not guaranteed along this route, in line with on-
the-ground reports from along the corridor [51, 52]. is
raises additional questions about Israel’s failure to pro-
vide civilian protections, especially on routes where civil-
ians are being mandated to go for their supposed safety.
e areas awaiting those who managed to evacuate
to the south were also not spared from damage, which,
combined with the overwhelming demand, led to lim-
ited services. Our data demonstrates that the evacuation
orders made for civilians put them in life-threatening
conditions, with direct and proximal damage to the criti-
cal civilian infrastructure in southern governorates where
civilians were directed to ee. Evacuation orders by the
Israeli military [51], under the auspices of civilian pro-
tection, instead placed signicant strain on already over-
whelmed critical civilian facilities. Health facilities in the
southern governorates of Gaza reported critical over-
ows of traumatic and burn injuries [53], with limited
capabilities to provide basic humanitarian services due to
ongoing attacks on infrastructure and limited humanitar-
ian aid creating a humanitarian catastrophe [54, 55].
Limitations
Our analysis is based on satellite imagery-based assess-
ments of likely damage, which lacks granular, building-
by-building detail that would improve our understanding
of the severity and types of damage to certain facilities
and infrastructure. e data also does not dierentiate
between types of attacks, whether from the ground or
from the air. e lack of ground truth data on locations
and type of structural damage also prevents the ability
to quantify the accuracy of satellite radar-based dam-
age assessments. While theoretically dicult to dier-
entiate between infrastructure damage caused by Israeli
munitions and Hamas munitions after the initiation of a
ground invasion by Israel, the unprecedented tonnage of
munitions [10] used and a military campaign described
as ‘the most destructive in recent history’ [56] makes the
likelihood of causes of overwhelming infrastructure dam-
age other than Israeli military munitions extremely low.
Conclusions
e rst phase of the Israeli military campaign in the
Gaza Strip from 7 October through 22 November 2023
resulted in widespread damage to critical civilian infra-
structure protected under IHL, including health, edu-
cation, and water facilities. Spatial statistical analysis
suggests widespread damage to critical civilian infra-
structure that should have been provided protection
under IHL. ese ndings raise serious allegations of
Israeli military violations of IHL, especially in light of
Israeli ocials’ statements explicitly inciting violence and
displacement and multiple widely reported acts of collec-
tive punishment against the Palestinian population in the
Gaza Strip.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s13031-024-00580-x.
Supplementary Material 1
Author contributions
DM, YA as co-rst authors, wrote the manuscript, conceptualized the study,
conceived and designed the analysis, and interpreted the data.DK, GG, SK,
CS, JV conceived and designed the analysis, contributed data and analysis
tools, and performed the analysis.SA, SH, NB interpreted the data and
provided revisions to the manuscript.KA provided wrote components of the
manuscript and provided revisions to the manuscript.BW, WH as co-senior
authors, conceptualized the study, interpreted the data, and provided
revisions to the manuscript.All authors reviewed and edited the manuscript.
Funding
N/A.
Data availability
Datasets used for this study may be found in Table1
Declarations
Ethical approval
The study was deemed not human subjects research and granted exemptions
by the Harvard Longwood Campus and University of California, San Diego
Institutional Review Boards’ decision tools.
Competing interests
The authors declare no competing interests.
Author details
1FXB Center for Health and Human Rights, Harvard University, Boston,
USA
2School of Global Health Management and Informatics, University of
Central Florida, Orlando, USA
3University of California San Diego School of Medicine, La Jolla, USA
4Harvard Humanitarian Initiative, Harvard University, Cambridge, USA
5Harvard Medical School, Boston, USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 12 of 13
Asi et al. Conict and Health (2024) 18:24
6College of Earth, Ocean, and Atmospheric Sciences (CEOAS), Oregon
State University, Corvallis, USA
7The Graduate Center, City University of New York, New York, USA
8Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
9Columbia University Mailman School of Public Health, New York, USA
10Institute of Community and Public Health, Birzeit University, Birzeit,
Palestine
Received: 8 January 2024 / Accepted: 11 March 2024
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