Summary

From the day the war broke out, they destroyed what was inside us. They demolished my house and my room, which held all my memories. They took everything that helped me to live, like my devices, my boot, and my wheelchair. How can I go back to how I was without all this?

— Ghazal, a 14-year-old girl with cerebral palsy in Gaza

Following the Israeli military order to evacuate Beit Hanoun in northern Gaza, 13-year-old Malek Al Kafarna fled south with his parents, 7-year-old brother, and 14-year-old sister. They first sought refuge in Jabalia refugee camp, then moved to Al-Shati refugee camp before eventually settling in Deir al-Balah, hoping for safety. However, on October 24, 2023, when Malek and his mother were at the central market in Nuseirat refugee camp, waiting for food coupons, an Israeli strike hit the market, blowing off Malek’s left arm. Malek waited for hours before receiving medical assistance due to an overwhelmed healthcare system, staff shortages, and lack of medical supplies.

Malek is just one of thousands of children in Gaza who have acquired a disability from injuries caused by explosive weapons since October 7, 2023. Before then, 98,000 children in Gaza between the ages of 2 and 17 already had a disability and were now encountering enormous difficulties to survive. Ghazal, a 14-year-old with cerebral palsy, had to flee from the north to the south of Gaza without her assistive devices, which she had lost in an attack that struck her family’s home. As of early May, Ghazal was displaced in a tent in Rafah, without proper and dignified access to water, food, and sanitation, or access to school and the physiotherapy she received prior to October 7. The challenges faced by Ghazal highlight some of the unique risks faced by children with disabilities in Gaza.

The actions by the Israeli military and the government’s blockade of Gaza, including severe restrictions on humanitarian aid, have inflicted profound trauma and suffering on Palestinian children, which has had a disproportionate impact on children with disabilities. As of September 18, ongoing Israeli strikes and ground operations have killed more than 41,000 Palestinians, including more than 16,750 children according to the Ministry of Health in Gaza. Previously, the Palestinian Civil Defense estimated more than 10,000 adults and children were missing under the rubble of destroyed buildings in Gaza. Attacks have also caused serious injuries that have led to permanent disabilities and lifelong scarring for Palestinian children. As of September 18, the Health Ministry in Gaza reported that more than 95,500 people had been injured. The World Health Organization estimates that more than 22,500 people of those injured as of July 23, 2024, have sustained “life-changing injuries,” requiring rehabilitation services “now and for years to come”. UNICEF reported that thousands of children have lost one or two limbs within the first three months of the hostilities.  

Israel launched its military operations in Gaza following the Hamas-led Palestinian armed groups’ attacks in southern Israel on October 7, 2023, in which, according to Agence France-Presse (AFP), more than 800 civilians, including 36 children were killed. The Palestinian armed groups took 251 people as hostages, including 40 children, according to AFP. Israeli airstrikes and ground attacks on Gaza, and resistance by Palestinian armed groups, including rocket strikes on Israel, have continued since then. In June, the UN Secretary-General Antonio Guterres issued his annual report on children and armed conflict – his “list of shame” – and for the first time included the Israeli armed forces to the list of parties to armed conflicts committing “grave violations” against children. The report found Israeli forces responsible for 5,698 grave violations, including the killing and maiming of children and attacks on schools and hospitals during the 2023 calendar year. Palestinian armed groups also committed 137 violations against children.

A million children are among the 1.9 million Palestinians who have been displaced from their homes and communities since October 7, and at least 19,000 children became orphans or otherwise ended up without a caregiver. Israeli government restrictions on humanitarian aid have deprived children of access to essential resources, like food, water, and medical care, resulting in a sharp rise in the number of children suffering from acute malnutrition. As of September 16, 38 Palestinians, the majority being children, have died of malnutrition and dehydration in hospitals, according to Gaza’s Health Ministry. In June, UNICEF reported that almost 3,000 malnourished children were at risk of death.

While the Israeli government’s longstanding blockade and more recent attacks have impacted all Palestinians, children with disabilities—whether acquired prior to October 7 or since—encounter particular risks due to both their age and disability. They face additional challenges in accessing essential food, water, sanitation, medical treatment, medicines, assistive devices, and services, all of which are extremely hard, if not impossible, to obtain due to frequent Israeli strikes and major ground operations and restrictions on the entry of humanitarian aid. Children with disabilities are also at heightened risk of death or injury from additional challenges they face when forced to flee attacks. People with disabilities are also at greater risk when Israeli forces do not provide civilians effective and accessible advance warning of attacks and adequate evacuation procedures.

The Israeli military has been using starvation of Palestinian civilians as a method of war in Gaza. This tactic has placed children with disabilities who require a specific diet at a particularly high risk of malnutrition and starvation. Israeli restrictions on water and destruction of Gaza’s water infrastructure have left the population without sufficient access to safe water or sanitation, which have further affected children with disabilities.

Israel’s arbitrary denial of and restrictions on humanitarian assistance have been exacerbated by Israeli forces’ attacks on hospitals, harming children requiring urgent medical assistance—including the loss of limbs in attacks—or ongoing care to meet the needs of children with disabilities or chronic health conditions. Injured children in need of immediate medical attention have endured inordinately long waiting times and undergone invasive surgeries without anesthesia. Children with disabilities and chronic health conditions have endured months without access to essential and other medicines. The uncle and caregiver of Muhammad, a 5-year-old boy with cerebral palsy and developmental disabilities, said his nephew does not have access to anti-convulsant and anti-epileptic medication that he used to take twice a day prior to October 7 due to unavailability or high costs. “I am so scared he will have muscle spasms,” his uncle said. “I would buy it regardless of the cost if I could just find it.”

The International Court of Justice, in its July 19, 2024 Advisory Opinion on the Occupied Palestinian Territory, held that the law of occupation still applies to Israel’s conduct in Gaza. As an occupying power that maintains significant control over many aspects of life in Gaza, Israel has obligations under international humanitarian law to ensure the welfare of the population there, specifically to provide for the food and health care of the population. Israel also has obligations under international human rights law including ensuring the population’s rights to food, water, health, and housing, among other rights, which are applicable during armed conflict as well as in peacetime. Israel’s continuing 17-year blockade of Gaza as well as severe restrictions on humanitarian assistance has resulted in violations of these rights.

Additionally, while UNICEF considers all children in Gaza to have experienced psychological harms from the violence and deprivation they have endured or witnessed, the mental health of children with disabilities has been uniquely impacted because of the challenges they face and their consequent worries and fears. “Mama, it’s over, leave me alone and run away,” Ghazal said, begging her parents, who had to carry her during their escape from northern to southern Gaza, to leave her and save themselves. Her mental health was further affected by the loss of her assistive devices that would have allowed her to take care of herself, and later, by her fear of a potential attack on Rafah and wondering how she would survive. Lack of access to schools, which have not been able to operate in Gaza for almost a year and many of which have been destroyed, exacerbates the mental health impact.  

The Israeli military’s use of explosive weapons with wide-area effects, such as aerial bombs and missiles, in densely populated areas raises significant concerns over Israel’s compliance with international humanitarian law, and has resulted in deaths, injuries and permanent disabilities among children. The nongovernmental organization Humanity & Inclusion reported in December that the main types of injuries sustained from the use of explosive weapons in Gaza are traumatic amputations—where a body part is partly or fully severed or lost during injury—of one or more limbs, fractures, peripheral nerve injuries, spinal cord injuries, traumatic brain injuries, and burns. Overcrowding and lack of medical equipment, supplies, and medicines has meant that beleaguered hospitals have been unable to prevent avoidable amputations or provide rehabilitation.

Both international humanitarian law and international human rights law provide for the protection of people with disabilities, including children, during armed conflict. International humanitarian law obligates warring parties to provide effective advance warning of attacks unless circumstances do not permit. Meeting this obligation generally requires that the intended recipient receives the warning and is able to act on it – such critical, life-saving information needs to be accessible to people with disabilities. International humanitarian law also recognizes the need to proactively identify people with disabilities in the distribution of humanitarian aid when humanitarian agencies assist warring parties to meet their obligations.

The UN Convention on the Rights of Persons with Disabilities (CRPD), ratified by Israel in 2012, obligates states parties to take “all necessary measures,” in accordance with international humanitarian law and international human rights law, to ensure the protection and safety of people with disabilities in situations of armed conflict.

In South Africa’s case alleging that Israel is violating the Genocide Convention, the International Court of Justice issued provisional measures on January 26, March 28, and May 24, 2024. In particular, the court ordered Israel to enable the provision of basic services and humanitarian assistance into Gaza, prevent genocide against Palestinians in Gaza, and ensure unimpeded access for fact-finding and investigative bodies, among other binding measures.

All parties to the conflict should comply with their obligations under international humanitarian law. Specifically with respect to people with disabilities, including children, in Gaza, Israel should refrain from using explosive weapons with wide area effects in populated areas; end the blockade and restrictions on humanitarian aid to Gaza and ensure the provision of  adequate  humanitarian aid in and throughout Gaza; cease unlawful attacks on hospitals, humanitarian convoys and staff; and adopt measures with respect to effective advance warnings of attacks and evacuation orders that take into effect the impact on people with disabilities.

Countries supporting Israel, notably the United States, United Kingdom, Canada, and European Union member countries, should condemn laws-of-war violations by all parties. They should specifically raise the harm to children during the conflict, including Israel’s use of explosive weapons in populated areas, its Gaza blockade and restrictions on humanitarian aid, and unlawful attacks on hospitals. In particular, concerned countries should press Israel to address the needs of Palestinian children with disabilities.

States should suspend military assistance and arms transfers to Israel so long as Israeli forces are committing abuses amounting to war crimes with impunity. States providing military and security assistance to Israel risk complicity in war crimes and grave human rights violations.  All governments should also use their leverage to press Israel to comply with the ICJ’s orders to prevent any acts of genocide and further mass atrocities, including by ensuring the unhindered provision of humanitarian aid. 

Methodology

Between December 17, 2023 and May 22, 2024, Human Rights Watch interviewed 20 family members of children with disabilities, a 14-year-old with a disability, five medical doctors, and eight representatives of humanitarian agencies, including the United Nations Children’s Fund (UNICEF), the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), the Palestine Children’s Relief Fund (PCRF), Medical Aid for Palestine (MAP), and the International Rescue Committee. Human Rights Watch remained in contact with 6 of the 20 family members until September 16, 2024, to include their most up-to-date information in the report.

All of the families we interviewed were displaced from their homes in Gaza. Five families had been evacuated—four for medical treatment—and were in other countries at the time of the interview; the rest were still in Gaza. All but two interviews with the families were conducted by phone in English with Arabic interpretation. Due to telecommunication and internet disruptions, some interviews took several days to complete, and a few were conducted through voice messages. One interview was conducted in person in Bosnian in Sarajevo, Bosnia and Herzegovina. Some interviewees asked Human Rights Watch not to use their full names for their protection, which we respected.

Human Rights Watch reviewed medical records of several children with disabilities included in this report with the permission of their families.  Human Rights Watch also reviewed over 50 videos and photographs showing the aftermath of attacks shared directly with researchers or collected from social media platforms, including Facebook, Telegram, YouTube, and X (formerly Twitter). By matching landmarks in the videos with satellite imagery, street-level photographs, or other visual material, and comparing information with open-source reports by other organizations, Human Rights Watch was able to corroborate some, but not all, of the witness accounts about attacks.

To protect the privacy and dignity of survivors and victims, Human Rights Watch has not included links to graphic videos and photographs available online. The videos and photographs used in the analysis of this report have been preserved by Human Rights Watch in case they are removed from online sources.

Human Rights Watch could not visit Gaza because Israeli authorities have blocked entry into Gaza and its crossings since October 7, 2023. Israel has repeatedly denied many Human Rights Watch requests to enter Gaza over the past 17 years.

On April 26, 2024, Human Rights Watch provided the Israeli military and Ministry of Defense with a summary of our findings and sought responses to specific questions. The letters are included as an annex. Neither had replied by time of publication.

This report is one in a series of in-depth research products that Human Rights Watch is publishing on the current hostilities between Israeli forces and Palestinian armed groups in Gaza.

Background

Israel’s Closure of Gaza

The Gaza Strip has been under Israeli occupation since June 1967.^[1] Despite having no troops permanently stationed in Gaza since 2005, in light of the continuing controls Israel has exercised over Gaza’s inhabitants, Israel remains the occupying power under international humanitarian law (IHL), also called the laws of war.^[2]  Israel has maintained overarching control over the movement of people and goods, territorial waters, airspace, population registry, and infrastructure.

Since 2007, Israel has imposed a closure of Gaza and banned, with narrow exceptions, Palestinians from leaving through Erez, the passenger crossing from Gaza into Israel, through which they can reach the occupied West Bank and travel abroad via Jordan.[3] Israeli authorities have also restricted the entry of goods via a second crossing point, the Kerem Shalom crossing on the Egypt border.[4]  The Israeli government has instituted a formal “policy of separation” between Gaza and the West Bank, despite international consensus that these two parts of the Occupied Palestinian Territory form a “single territorial unit.”[5] Israeli authorities have also denied Palestinian refugees in Gaza—people who were expelled or fled in 1948 from what is now Israel and their descendants, constituting more than 80 percent of Gaza’s population—from returning to the areas they are from.[6]

Human Rights Watch has found that under international humanitarian law during an occupation, Israel’s prolonged closure of Gaza is a form of collective punishment.[7]  In addition, Israeli authorities have been committing crimes against humanity of apartheid and persecution against Palestinians, including in Gaza.[8]

Prior Hostilities and Israeli Military Actions in Gaza since October 7, 2023

Over the past 17 years, Israel and  Palestinian armed groups in the Gaza Strip have engaged in several rounds of hostilities, including in 2008-2009, 2012, 2014, 2018, 2019, and 2021.[9] Human Rights Watch and others have documented numerous grave violations of the laws of war, many amounting to war crimes, committed by Israeli forces and Palestinian armed groups.[10] There has largely been impunity for abuses by both sides.[11]

On October 7, 2023, Hamas-led Palestinian armed groups carried out an assault on military targets and civilians in Israel. Agence France-Presse said it assessed that 815 civilians were killed during and after the attack, including 36 children—at least two of whom had a disability—and the taking of 251 hostages, including 40 children.[12] Human Rights Watch concluded that during the attack, Palestinian armed groups committed war crimes and crimes against humanity of murder and unlawful imprisonment.[13] Israeli forces responded with almost a year-long  military assault on Gaza that has resulted in the killing of more than 41,000 Palestinians as of mid-September 2024, according to the Ministry of Health in Gaza, including more than 16,750 children, the UN Committee on the Rights of the Child reported.[14]

Thousands more children are reported missing and may be trapped under the rubble of destroyed buildings.[15] More than 95,500 people have reportedly been injured, according to the Gaza Ministry of Health.[16] The Palestinian NGOs Network (PNGO) reported on June 29 that about 10,000 people, half of them children, are estimated to have acquired a disability since October 2023.[17] The World Health Organization estimates that more than 22,500 people of those injured as of July 23, 2024, have sustained “life-changing injuries,” requiring rehabilitation services “now and for years to come”.[18] Save the Children reported in January that more than 10 children were losing one or both legs per day.[19]  

Since the October 7 attacks, Israeli authorities cut off essential services, including water and electricity, to Gaza and blocked the entry of all but a trickle of fuel and critical humanitarian aid, acts of collective punishment that amount to war crimes.[20] Israeli authorities have also been using starvation of civilians as a method of warfare in Gaza, which constitutes a war crime.[21]

Israeli forces continue to conduct numerous airstrikes and large-scale ground operations in the hostilities in Gaza with Palestinian armed groups. Many of these attacks, including attacks that were unlawfully indiscriminate, have hit residential buildings and hospitals, reducing large parts of neighborhoods to rubble.[22] As of mid-March, Israeli authorities had ordered the evacuation of everyone from northern Gaza, which displaced 1.7 million people, about 75 percent of Gaza’s population. More evacuations have occurred since then in southern Gaza as well. According to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), as of August 7, 1.9 million people are internally displaced, amounting to 90 percent of Gaza’s population.[23]

On January 26, the International Court of Justice issued binding “provisional measures” that require Israel to prevent genocide against Palestinians in Gaza, enable the provision of basic services and humanitarian assistance, and prevent and punish incitement to commit genocide, among other measures. The court ordered Israel to take all measures in its power to prevent the commission of any acts prohibited under the Genocide Convention  in relation to Palestinians in Gaza, including killing members of the group, causing serious bodily or mental health harm to members of the group, and deliberately inflicting on the group conditions of life calculated to bring about the group’s physical destruction in whole or in part.[24] Human Rights Watch found that Israeli authorities were not complying with the court’s orders by obstructing the entry of lifesaving aid and services into Gaza.[25] On March 28, the court found that its January 26 order did not “fully address the consequences arising from the changes in the situation,” and issued new provisional measures ordering Israel to ensure the “unhindered provision” of humanitarian assistance. On May 24, the court issued a third order, ordering Israel to ensure humanitarian assistance among other provisional measures.[26]

The impact of Israel’s military actions on children in Gaza

Israel’s military offensive in Gaza has taken a tremendous toll on the civilian population, particularly children, who make up almost half of the population.[27] The government’s actions have inflicted profound trauma and suffering upon Palestinian children, including those with disabilities, who were 15 percent of children in Gaza, according to the UN.[28] Although there are no official numbers of how many children with disabilities are among the more than 16,750 children who, according to data from the Gaza Ministry of Health cited by the UN, have been killed since the start of Israel’s military operations in Gaza, media outlets have reported on the killings of both children who had a disability prior to October 7 and children who have acquired a disability since.[29] Israeli military  strikes and ground attacks have also caused serious injuries that have led to permanent disabilities and lifelong scarring for Palestinian children. Referring to child casualties, the UN secretary-general Antonio Guterres said that Gaza is becoming a “graveyard for children” where “hundreds of girls and boys are reportedly being killed or injured every day.”[30]

In June, Guterres issued his annual report on children and armed conflict—his “list of shame”—and for the first time included the Israeli armed forces to the list of parties to armed conflicts committing “grave violations” against children.[31] The report found Israeli forces responsible for 5,698 grave violations, including the killing and maiming of children and attacks on schools and hospitals during the 2023 calendar year.[32] Palestinian armed groups also committed 137 violations against children. The secretary-general noted reported but unverified grave violations against 3,900 Israeli children and 19,887 Palestinian children during 2023.

Guterres said, “I am appalled by the dramatic increase and unprecedented scale and intensity of grave violations against children in the Gaza Strip, Israel and the occupied West Bank, including East Jerusalem, despite my repeated calls for parties to implement measures to end grave violations.”  He “urge[d] all parties to the conflict to immediately end and prevent grave violations against children … and to adopt immediately clear, time-bound commitments to end and prevent grave violations against children, as proposed by the United Nations, and to comply with international humanitarian law and international human rights law.”[33]

Save the Children reported in June that up to 21,000 children were estimated to be missing, including many dead under rubble, detained, buried in unmarked graves, or separated from their families.[34] The UN Committee on the Rights of the Child reported in mid-September the “outrageously high number of children in Gaza who continue to be killed, maimed, injured, missing, displaced, orphaned and subjected to famine, malnutrition and disease,“ citing Israel‘s “attacks on Gaza using explosive weapons with wide-area effects in densely populated areas and its denial of humanitarian access,“ which has displaced at least 1 million children and pushed 3,500 children to risk death from malnutrition.[35]

While the Israeli government has repeatedly stated that its war aims are to destroy Hamas and to free the hostages taken during the Hamas-led attacks on Israel on October 7, several statements by Israeli officials, indicate an intent to inflict harm on the civilian population, including children. On October 28, 2023, prior to undertaking a ground attack on Gaza, the Israeli prime minister invoked the biblical story of the total destruction of Amalek by the Israelites, stating: “you must remember what Amalek has done to you, says our Holy Bible. And we do remember.”[36] He referred again to Amalek in a letter sent on November 3, 2023, to Israeli soldiers and officers.[37] The relevant biblical passage is: “Now go, attack Amalek, and proscribe all that belongs to him. Spare no one, but kill alike men and women, infants and sucklings, oxen and sheep, camels and asses.”

Similarly, during an October 12 press conference and referring to Palestinians in Gaza, where over one million of the population are children, President Isaac Herzog stated: “It’s an entire nation out there that is responsible. It’s not true this rhetoric about civilians not aware not involved. It’s absolutely not true. … and we will fight until we break their backbone.”[38]

In addition to the prime minister, the only other remaining member of the emergency government with decision-making power is the Israeli Minister of Defense, Yoav Gallant, who stated that Israel was “imposing a complete siege on Gaza. No electricity, no food, no water, no fuel. Everything is closed. We are fighting human animals and we are acting accordingly.”[39] He also stated that: “Gaza won’t return to what it was before. We will eliminate everything. If it doesn’t take one day, it will take a week. It will take weeks or even months, we will reach all places.”[40] He further announced that Israel was moving to “a full-scale response” to the Hamas-led attack and that he had “removed every restriction” on Israeli forces. "Hamas wanted to see a change in Gaza – the reality is Gaza will make a 180. They will regret [their actions]," Gallant said.[41]

Serious Injuries to Children from Israeli Military Use of Explosive Weapons

Serious Injuries to Children

Children have unique vulnerabilities to the direct effects of explosive weapons.[42] For instance, they are more susceptible to burns and are more likely to die from blast injuries than adults.[43] UNICEF has said that the physical injuries caused by explosive weapons also have severe psychological, educational, and social impacts; and result in economic and environmental degradation, “severely affecting children’s access to essential services, like healthcare, education and water.”[44]

Humanity & Inclusion, an international organization focused on providing support to people with disabilities, including in Gaza, reported in December that the main types of injuries sustained from the use of explosive weapons in Gaza were traumatic amputations (where a body part is partly or fully severed or lost during injury) of one or more limbs, fractures, peripheral nerve injuries, spinal cord injuries, traumatic brain injuries, and burns.[45]  According to UNICEF, in the first three months of the Israeli military campaign in Gaza, thousands of children lost one or both of their legs, and many were amputated and treated without anesthetic.[46]  

Unexploded ordnance is an additional concern, particularly to children. Humanity & Inclusion said that while it was impossible to know the full extent of the explosive remnant contamination in the Gaza Strip, a “significant increase” was expected, which will “undoubtedly cause further loss of life, limb, and psychological trauma for many years to come.”[47] The UN Mine Action Service said in late April that the exposure to unexploded ordnance in Gaza was now at its “most dangerous stage.”[48]

Three doctors, including two in emergency medicine—Dr. A.G. (a pseudonym), who worked at al-Shifa Hospital in Gaza City; Dr. Haytham Ahmed, who worked at Al-Nasser hospital in Khan Yunis; and Dr. Seema Jilani, a pediatrician and senior technical advisor for emergency health at the International Rescue Committee, who completed a two-week-long medical mission in Gaza—told Human Rights Watch that the majority of injuries they had seen among children were from burns. The next most prevalent type of injuries were traumatic limb amputations.[49] Dr. A.G. described injuries he treated or witnessed:

We are talking about a huge number of traumatic amputations, especially in children, leaving children with permanent disabilities. Also, many children who were wounded by shrapnel all over their faces and bodies, and I have seen children lose their eyesight due to injuries.[50]

Dr. Jilani, who worked in Al Aqsa Hospital between December 25 and January 8 for the International Rescue Committee and Medical Aid for Palestine, described seeing limbs blown off from explosive weapons in children. She also observed children with head trauma and severe burns.  

Family members told Human Rights Watch about injuries sustained by their children from Israeli forces’ use of explosive weapons.[51]

Malek, 13 (Traumatic Amputation)

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Leila Al Kafarna, a mother of three children ages 7, 13, and 14, said the Israeli order to evacuate Beit Hanoun in northern Gaza led her and her family to flee on foot to Jabalia refugee camp on October 9 at around 1:30 a.m. She said their nighttime journey was harrowing, especially for her young children and her 84-year-old husband, who has prostate cancer and difficulties walking. She said, “There was no help or transportation available, so I carried my husband on my back to Jabalia.” They arrived at about 4:30 a.m. at the crossing near Abu Zaytoun Schools. Leila said that a strike by Israeli forces hit the area that morning and killed an unspecified number of people from her husband’s family. Some of the names of those killed in the Al Kafarna family, provided by Leila, match the description of an October 9 attack in Jabalia documented by Airwars, a nongovernmental organization (NGO) that investigates civilian harm in conflict zones.[52]

The following day, fearing that Jabalia might be attacked again, Al Kafarna and her family fled to Al Shati refugee camp, where her brother had a house. According to Al Kafarna, five days later—around October 16—an apparent Israeli strike hit the mosque next to the house, destroying the second floor of her brother’s house. “We were all injured, but thank God most of the injuries were not severe,” Al Kafarna said. Her family fled yet again to a nearby school, in Beach Camp, where they sustained minor injuries in another nearby attack, which a witness said may have targeted a car with Palestinian fighters.[53] Al Kafarna said that the head of the school then advised people sheltering there to leave because the school was at risk. Al Kafarna’s family subsequently walked miles along the beach to Nuseirat camp in central Gaza, which the Israeli military had declared safe, and where Al Kafarna’s aunt had a house.[54] She described the journey: “I carried my husband on my back, and we kept walking on foot through the sand and gunfire over our heads and planes dropping leaflets. Our children screamed along the way. It felt like the whole world ran and screamed with fear.”

Al Kafarna recounted experiencing a strike, which the UN Office for the Coordination of Humanitarian Affairs (OCHA) reported as a series of Israeli airstrikes on October 24 that damaged Abu Dalal Mall, Nuseirat camp’s central market, and left at least 20 people dead.[55] Al Kafarna said:

We finally felt a bit relieved and on October 20, Malek, my 13-year-old son, and I went to the market…. We went there for four consecutive days, waiting in line to get our [food] coupon, and it was on our fourth day that the attack happened.

We were there for an hour-and-a-half. Suddenly, I felt something was off. I took Malek’s hand and told him we needed to leave, and that was when I heard something breaking from the walls. I looked up as the missile [munition] was hitting the supermarket, and I lost consciousness…. We were thrown away by the impact and surrounded by rubble. There were people and bodies around and on top of us. Body parts were everywhere.

I woke up with a fire near my face, like a meter away, and I was still holding my son’s arm, so I started running, thinking I’m running with my son.... I was screaming at him to run fast before they bomb again, and then I felt like my son was light, as if there was no weight on the arm. So, I looked and didn’t see my son anywhere near me, and that was when I discovered that I was holding only his arm.

I put the arm down and ran back, and I saw my son running and screaming “Allah, Allah,” and he started telling me to forgive him for any day he treated me badly, as if he was saying goodbye. Malek then fainted.[56]

An ambulance took them to Al-Aqsa hospital. Malek survived, but he lost his left arm. Al Kafarna and Malek were evacuated to the United Arab Emirates (UAE) on December 19, where Malek underwent several surgeries and received a prosthetic.  Malek was still receiving treatment as of July 20. Al Kafarna had to leave her two other children and her husband behind in Gaza and they had not been reunited as of September 2024.

Human Rights Watch verified video taken after the attack and posted to social media on October 24 showing dead and wounded people in civilian clothing, including children, in front of the supermarket.[57] Media outlets reported that the apparent target of the attack was a house above or next to the mall.[58] The Israeli authorities have not provided any information about the attack.

Ahed, 17 (Traumatic Amputation)

Dr. Hani Zouher Bseiso, an orthopedic surgeon who previously worked in al-Shifa Hospital, Gaza City, said that his 17-year-old niece Ahed had part of her leg blown off when an Israeli tank shell hit their house in Gaza City on December 19 at about 10 a.m. He believed it was an Israeli tank shell because tanks had surrounded their house for days before the incident. Ahed had gone up to the roof to call her father, who lives in Belgium, like she did every day. Bseiso said that only civilians lived in the house, adding that:

What affected me the most is that I wasn’t there for her when she got injured, it took me like three or four minutes to reach her…. She kept asking for me, saying “bring my uncle,” so I arrived and didn’t know what to do or where I should start. For a second, I just stood there and froze. I didn’t have anesthesia or my medical equipment and I had to decide the best and easiest way to save her life.[59]

Bseiso operated on Ahed on a dining table because they could not reach a hospital due to the heavy presence of Israeli forces.[60] He did not have the necessary equipment, such as surgical suture, so he used a sewing needle and thread for stitches.[61]

Human Rights Watch reviewed a video, first posted on Instagram on January 15 and published by media outlets later that month, that appears to show Ahed lying on a dining table with the lower half of her mangled right leg missing. Bseiso explains as he washes her leg in a bucket that he is forced to amputate without anesthesia.[62]

According to Reuters, the Israeli military did not respond to specific questions about the December 19 shelling of the Bseiso family home.[63]

Alaa, 7 (Traumatic Amputation)

Ahmed, the father of Alaa, 7, and Omar, 3, said their family was injured in an aerial attack by Israeli forces on November 21 at 4 a.m., which hit their building in Nuseirat refugee camp, where he and other displaced families from northern Gaza had taken refuge.[64] According to Yasser, Ahmed’s brother, this attack killed 13 family members, including Alaa and Omar’s grandfather, aunt, and cousins, including children. Alaa lost a hand in a traumatic amputation.[65]

Both Ahmed and Yasser said that their building housed only civilians. “The stairs were completely destroyed, only one room was standing, that’s where we were and why we survived,” Yasser said. “It took us 10 days to realize who was alive and who was killed.”[66]

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When Alaa and Ahmed were taken to a hospital, Yasser said he was shocked to see staff operating without anesthetic.[67]

Human Rights Watch has not been able to independently confirm the details of the attack.

Ahmed, 9 Months (Traumatic Amputation)

Mohammed and Tahani Abu Masir, father and mother to 9-month-old Ahmed Abu Masir, independently told Human Rights Watch that Ahmed’s head and legs were injured during Israeli airstrikes on their residential neighborhood in Deir al-Balah between 10 and 11 a.m. on December 2, 2023, the day after the temporary ceasefire ended. Ahmed lost his left leg and his right leg was seriously injured. Mohammed said:

We thought they would update or push for a ceasefire for another day, but then the attacks started. I was at my house with my family. We are civilians, we don’t have anyone who is with Hamas: I am a driver; my wife is a teacher; my brothers, most of them are drivers; some wives are at home with kids. The attack that happened that day hit my house and my uncle’s house. Nine people died from my uncle’s house and two from mine. In addition to Ahmed, 14 other people were injured, including my second cousin’s child.[68]

 Tahani described the moment of the attack, as children were playing and adults were carrying out household chores:

When we were hit, everything turned dark. It took us a while to realize what was happening. You lose a sense of what’s happening around you, even who you are. It was such a shocking experience that I didn’t even realize Ahmed had lost a leg in the attack. When I arrived at the hospital, I saw that one leg was gone.[69]

Sara, 9 (Severely Injured Hip)

Khuloud, Ahmed Abu Masir’s aunt and a mother of three, recounted the same attack. Her 9-year-old daughter, Sara, who had Ahmed in her lap at the time, suffered severe injuries and has since been unable to walk. Sara’s family had fled to Deir al-Balah from Zaitoun, following the Israeli authorities’ order to evacuate to the south, and was sheltering at the Abu Masir home. She described the same attack:

There was no warning, just a loud sound. Everything became dark, and it took me a moment to realize we had been targeted. Everyone started screaming, trying to find each other.

We heard Sara’s voice under the rubble. We removed the rubble with our bare hands, and when we found her, we saw she was badly injured. Her uncle carried her toward the hospital, and I started running after them barefoot.[70]

Khuloud said Sara’s hip was broken and the flesh covering it was gone.[71]

Both Tahani and Khuloud Abu Masir said two of their extended family members—siblings Nour, 7, and Kinan, 5—were killed in this attack.

Khuloud said that 9 or 10 people were killed in the house next door, including two children. Khuloud’s brother and father had been killed by an earlier attack during these hostilities.

Layan, 12 (Medical Amputation)

After Israeli authorities ordered Palestinians living in northern Gaza to evacuate on October 13, 12-year-old Layan Al Atta and her family left the Shejaiya neighborhood of Gaza City to seek safety in Deir al-Balah.[72] On December 2, while standing outside her tent in the yard of Deir al-Balah Martyrs School, Layan sustained multiple fragmentation injuries from apparent artillery that reportedly struck the Anas Ibn Malik mosque, which was close to the school.[73] Human Rights Watch reviewed medical records and spoke to Raghda, who said that Layan received critical injuries to her back, chest, and right leg. A medical assessment of her injuries reviewed by and on file with Human Rights Watch indicated that her injuries were consistent with fragmentation (or metal fragments) from the munition detonation.[74]

“They hit us without warning even though the school was known to be full of people, especially kids and women,” Raghda said. 

Airwars collected preliminary information about civilian casualties in this December 2 incident, which it listed as a contested strike due to lack of sufficient information. Airwars and other sources suggest that suspected Israeli artillery struck Anas Ibn Malik mosque, with at least four children wounded in the nearby shelter school.[75]

Layan was among the few injured Palestinians allowed to leave Gaza for treatment, albeit a week after her injury. Due to the delay, by the time she got medical treatment in Egypt, her wounds were infected and gangrenous and she had developed sepsis and liver dysfunction. Doctors decided to amputate her right leg below the knee.[76] Later, Layan had to have another surgery to treat an ulcer on her left buttock. On April 4, Raghda said Layan urgently needed adequate rehabilitation and access to a prosthetic that was difficult to obtain in Egypt. On July 21, Layan was evacuated to the United States for further treatment.[77]

Dr. Haytham Ahmed, an emergency doctor at Nasser Hospital in Khan Younis, southern Gaza, said that due to heavy fighting, many of the injured cannot always reach a hospital to receive adequate treatment in time to avoid an amputation: “Yesterday, a girl came in four days after her injury. Her thigh injuries were gangrenous. We are fighting against time.”[78]

Two family members of children who had disabilities and chronic health conditions before October 7 described injuries the children received from aerial attacks.

Nour, 14, with Down Syndrome (Fragmentation Injuries)

Nour Ghandour, a 14-year-old girl with Down syndrome, was seriously injured during an apparent Israeli airstrike on her home in Khan Yunis on December 3, according to her 35-year-old sister Doaa, who said she heard an airplane a few seconds before. Human Rights Watch reviewed media reports and video posted to social media on December 3 showing the family’s building heavily damaged and Nour in the hospital covered in dust with a serious injury to her arm, which Arabic language media attributed to Israeli airstrikes.[79]  

Doaa’s parents, a sister, and a brother were killed, according to Doaa, who said no warning preceded the attack. Nour’s father was a prominent lawyer, a former director general at the Ministry of Justice and a former head of the Legal Department at the Ministry of Foreign Affairs in Gaza. Doaa recounted the attack:

[On December 3] I checked my phone and saw it was 6:53 a.m. Minutes later, I heard the sound of a warplane very, very close; I never heard it so close before. At that moment, before I could do anything or even blink my eyes, I felt the whole world start shaking extremely hard….

When I regained consciousness, I found myself in a room filled with dust. There was a guy standing at the end of this room; I can remember his shocked eyes. I heard another person say to me, “Please help us to get you up.” I realized there were two guys, one holding my arms and the other holding my legs. They were trying to get me up…. Soon after, I was shocked to realize I was already on the ground floor, which was unbelievable to me since just a few minutes earlier I had been lying in my bed in our apartment on the third floor.[80]

Doaa said she feared she had lost her youngest sister, Nour, who had been sleeping in the same room as her. It was only when Doaa reached the hospital that she found Nour with fragmentation injuries to her face and a severe injury to her right arm, which required surgery. While at the hospital, she learned that her parents, two siblings, and a sister-in-law had been killed.

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Osama, 3, with Combined Immune Deficiency (Inhaled Dust)

The mother of Osama, a 3-year-old boy with severe combined immune deficiency, a life-threatening health condition affecting the immune function, said that he inhaled dust following an attack on the Al-Shujaiya neighborhood in Gaza City in late October 2023.[81] For people with Osama’s condition, the inhalation of foreign particles like dust can be extremely dangerous. Following the attack, Osama, who had previously been prescribed and received regular physical respiratory therapy, experienced difficulties breathing, so his mother took him to Al-Nasr Pediatric Hospital, west of Gaza city, on October 30. Due to its lack of medical staff and equipment, Osama could not receive adequate treatment and his condition deteriorated further.

Al Jazeera reported that the Israeli military attacked the entrance of Al-Nasr Hospital on November 4.[82] His mother said she was still in the hospital with him when the Israeli military attacked, causing Osama to inhale more dust. The two fled the hospital on November 7 because Israeli forces were at the hospital gate, his mother said.

On November 10, medical staff and health officials told Al Jazeera they evacuated the hospital on the Israeli military’s order.[83] That day UNICEF raised concerns over reported attacks against al-Nasr Pediatric Hospital.[84]

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Osama’s breathing deteriorated at home and “he was completely unable to eat,” said his mother. She also said she did not have access to nutrient-rich food that Osama required because of his condition. She herself faced additional risks as she was in the advanced stages of pregnancy when the Israeli military operations in Gaza began. She described being delayed in reaching a hospital due to security concerns when she went into labor. She lost a significant amount of blood during the delivery on October 18, but the hospital lacked the facilities to provide her with a blood transfusion. The family was struggling to obtain food, which harmed her ability to breastfeed her newborn daughter. “There wasn’t any healthy food,” she said. “I was living on anything we could find.”

As of March, nearly 60,000 pregnant women in Gaza were suffering from malnutrition, dehydration and lack of proper health care, according to the Ministry of Health in Gaza.[85]

When Osama’s condition deteriorated, his mother went back to Al-Nasr Hospital. “I could not find any pediatricians,” she said. “I was told they had either been abducted by the occupation forces or had left to the south.” The Israeli military has detained at least 310 healthcare workers while on duty in Gaza since October 7, according to the  Gaza Ministry of Health, including 128 who remain in detention according to the World Health Organization.[86] Since no adequate treatment was available in Gaza City by that point, Osama’s mother took him to Al-Aqsa Martyrs Hospital in Deir al-Balah, where doctors inserted a nasogastric tube to provide him with nutrients and prevent dehydration. “Due to his condition, they told me he needed immediate medical attention outside of Gaza,” she said. Two weeks later, they were evacuated to the UAE, where, as of March 1, Osama was still receiving treatment at a hospital and regaining his weight.

Use of Explosive Weapons in Populated Areas

The Israeli military has extensively used explosive weapons in populated areas in Gaza. The effects of the use of explosive weapons on civilians are increasingly well-known and well-documented.[87] The Israeli military has reported that between October 7 and February 20, it carried out 29,000 airstrikes in Gaza.[88]  According to a CNN investigation published in mid-December, the United States Office of the Director of National Intelligence assessed weapons used by Israeli forces and found that about 40 to 45 percent of the 29,000 air-to-ground munitions fired against targets in the Gaza Strip were unguided.[89] Israel’s military has dropped 75,000 tons of explosives on the Gaza Strip as of April 2024, according to figures released by the Government Media Office, where 10 percent did not explode.[90]

The use of explosive weapons with wide-area effects in populated areas is one of the gravest threats to civilians in armed conflict. According to the International Network on Explosive Weapons—co-founded by Human Rights Watch—when explosive weapons are used in populated areas around the world, approximately 90 percent of those killed and injured are civilians.[91] They both cause civilian casualties directly, and frequently damage or destroy civilian infrastructure, such as hospitals and schools, causing indirect long-term or “reverberating” harm to civilians. Their use raises serious concerns that attacks are likely to indiscriminately harm civilians and civilian objects in violation of international humanitarian law.

Explosive weapons used in populated areas force people to flee their homes, exacerbating humanitarian needs. Munitions with large amounts of explosive material can spread fragmentation unpredictably over a wide area and produce a powerful blast wave that can cause severe physical injuries, blunt force trauma, physical damage from flying debris, and cause or exacerbate other injuries or existing disabilities.

States Providing Arms and Military Assistance to Israel

The United States is the biggest supplier of weapons to Israel, and it has increased its military assistance since October 7. The US has provided at least $12.5 billion in military aid to Israel at the time of this writing in 2024.[92]

Germany is the second biggest supplier to Israel, with €862 million ($916 million) in arms sales to Israel between 2015 and 2019.[93] In 2023, the government authorized military equipment worth approximately €326.5 million, marking a tenfold increase from 2022.[94]  Other major providers include the UK, Italy, and Canada.[95] 
 

Impact of Attacks on Health Care and Children with Disabilities

Damage and destruction of Gaza’s healthcare facilities during the hostilities, coupled with harm to medical professionals and health workers, has undermined the right to health.  Children are the most affected and children with disabilities who are in need of ongoing access to medical care have been disproportionally impacted.[96]

The following section looks at the impact of Israeli military attacks that have damaged or destroyed hospitals and other healthcare facilities in Gaza and the difficulties civilians, particularly children with disabilities, have faced in gaining access to medical care during the hostilities.

Attacks on Hospitals

Between October 7, 2023 and  August 20, 2024, Israeli forces carried out 505 attacks on healthcare in Gaza, causing 752 deaths and 982 injuries, according to WHO.[97] The attacks have left Gaza with 17 partially functioning hospitals, making it nearly impossible to respond to the enormous needs of the population.[98] According to Medical Aid for Palestine, the Israeli military’s continued bombardment of Gaza and attacks on healthcare facilities have severely affected health workers, whose deaths reportedly surpassed the total reported deaths of healthcare workers in global conflicts in 2021 and 2022 combined.[99] The organization concluded that “there is no safe place left in Gaza – not for healthcare workers, not for children, not for civilians, not for aid workers.”[100]

International humanitarian law provides special protections to medical personnel, hospitals and other medical facilities, including transports. While other presumptively civilian structures become military objectives if they are being used for a military purpose, hospitals lose their protection from attack only if they are being used, outside their humanitarian function, to commit “acts harmful to the enemy,” and if a reasonable warning to cease this misuse is given.[101]

The Israeli military has alleged that Hamas has used hospitals for “command centers” and other military purposes.[102] Human Rights Watch found that Israeli forces have committed repeated, apparently unlawful strikes on medical facilities, personnel, and transports, which alongside Israel’s blockade has decimated Gaza’s healthcare system and impacted the ability of staff to provide medical care.[103]   

Dr. Seema Jilani, who spent two-weeks at Al-Aqsa Hospital, said her visit was cut short by Israel’s order to evacuate the hospital:

I saw a semi-functional hospital become unable to function because of the mass casualties, lack of supplies, inability of staff to reach the hospital, and security constraints. One day while I was there, a bullet went in through the ICU. And in the following few days, Israel dropped leaflets in the surrounding area, the red zone, asking people to evacuate. We were not able to return after that.[104]

A December 2023 discussion paper by the UN special representative of the secretary-general on children and armed conflict highlighted that attacks on hospitals and their detrimental effects may be exacerbated for children with disabilities who may need ongoing or specific medical care, rehabilitation, or assistive technology.[105]

Human Rights Watch found that family members of children with disabilities and medical staff said that the Israeli forces’ actions have reduced the capacity of healthcare service providers and the availability of healthcare goods necessary for both urgent medical assistance and ongoing treatment. Two of the children with disabilities previously received regular medical care at al-Rantisi hospital, which has not been operational since November 2023.[106] 

Even before October 7, the Israeli government exercised full control over the type and amount of medical goods and supplies that could enter Gaza.[107] Since 2010, Israeli authorities have restricted and often prohibited what they deem “dual-use” items (civilian items that could be used by Hamas and other armed groups for military purposes).[108] However, according to WHO, the government’s “dual-use” list includes both overly broad categories and items that are vital to meet the needs of the population in Gaza, including certain kinds of medical equipment, including X-ray equipment and spare batteries for electric wheelchairs and other equipment needed by people with disabilities.[109] OCHA has said that these “restrictions impede the delivery of humanitarian assistance, basic services and reconstruction programs, and undermine the response capacity for emergencies.”[110]

Human Rights Watch has previously documented that the Israeli government’s closure of Gaza and restrictions on movement severely limited access for people with disabilities to services needed because of their disabilities, such as early intervention, and services designed to minimize and prevent further disabilities.[111] People with disabilities in Gaza also reported they faced difficulties obtaining assistive devices, such as wheelchairs and hearing aids, due largely to Israeli import restrictions.[112]

Since October 7, Israeli authorities have repeatedly refused to allow UN aid teams to deliver many types of necessary medical supplies, including anesthetics, into Gaza.[113] In addition, certain medication and supplies specifically needed by people with disabilities, such as ventilators, psychosocial support kits, and assistive devices, such as crutches, were denied entry.[114]

Such practices limit access to health services and to good quality health facilities, goods, and services, especially for people with disabilities and other groups facing higher risks during conflict.[115]

Aid workers said that the limited amount of aid and the arbitrary rejection of critical items have meant that the enormous need for aid cannot be met.[116] Israeli authorities have not provided a list of barred items, and inspections staff were rejecting entire truckloads in an apparently arbitrary manner without explanation or the possibility of appeal.[117] Israeli authorities generally do not allow aid agency representatives to be at the checkpoints where aid trucks are inspected.

Difficulties Obtaining Adequate Care at Hospitals

Even where there is a functioning medical facility in their vicinity in Gaza, children, particularly those with disabilities, face an array of serious obstacles when seeking care. These include the lack of safe access to health facilities; inadequate access to healthcare goods and services in hospitals; overcrowding in functioning hospitals; the inability of hospitals to provide children necessary treatment; the unavailability or unaffordability of essential medicines for children; closure of pediatric hospitals; shortages of early intervention services and treatments; and a need for evacuations outside Gaza to obtain adequate care.

Lack of Safe Access to Health Facilities

Even where hospitals continue to function, if only barely, the presence of Israeli forces, such as armored vehicles, has effectively prevented civilians needing medical care safe access.  

Dr. Bseiso, who operated on his niece Ahed’s leg at a dining table, described his emotional pain and fear because it was not safe to take her to a medical facility:

I used whatever equipment I had in the house and in the kitchen. I had to use a normal string instead of a medical one to stitch it to stop the bleeding….

The Israeli tanks were surrounding us and after I did her surgery, she asked, “If the Israelis come in, are you going to leave me?” I told her, “Your fate and my fate are the same, I won’t leave you.”[118]

They waited for five days, while Ahed’s situation deteriorated without adequate treatment, until the Israeli army had left, and Dr. Bseiso felt it was safe enough to take Ahed to Al-Shifa Hospital. Unable to access care in Al-Shifa Hospital, Dr. Bseiso took Ahed to another clinic. “We did perform most of the surgeries she needs,” he said. “But she needs additional operations on her left leg and most importantly, the installation of a prosthetic.”[119] In February 2024, PCRF evacuated Ahed to the United States for treatment.

Inadequate Access to Healthcare Goods and Services in Hospitals

Semi-functioning hospitals have been overcrowded and lack goods and supplies, including medicines needed by children with disabilities. Médecins Sans Frontières (MSF) reported in late April that people with chronic conditions or people with other medical needs were unable to receive the care they require because the few remaining functioning facilities were “being pushed to the brink, overwhelmed with patients with conflict-related trauma injuries.”[120] MSF also said that people with mental health conditions, such as bipolar condition or schizophrenia, do not have access to their regular treatment because the only psychiatric hospital in the Gaza Strip, which was in Gaza City, ceased functioning on November 6, 2023.[121] MSF said: “Without access to medical care, thousands more lives will be lost, beyond those killed in the Israeli bombardments seen in the news – these are Gaza’s ‘silent killings.’”[122]

The Office of the UN High Commissioner for Human Rights says that states’ obligations to the population under their effective control during armed conflict includes ensuring the availability, accessibility, and acceptability of quality health facilities, goods, and services.[123]

Dr. Haytham Ahmed, who works at Nasser Hospital, said that the lack of medical supplies and personnel has impacted the hospital’s ability to treat injured children. He added that the staff uses the term “hopeless case” to refer to a child or adult with high-degree burn injuries or multiple fragmentation injuries to the abdomen; he believed they could have received better treatment if specialists, specialized equipment, and even medical staff in general had been available. “We are left to deal with injuries that we do not know how to deal with, and without the right equipment,” he said.[124] Dr. Victoria Rose, a consultant plastic surgeon who was on a mission to European Gaza Hospital in Khan Yunis between March 21 and April 7, similarly said: “Lots of people are dying that do not necessarily need to die if we had the right number of doctors and nurses and kit.”[125]

Dr. Ahmed added that time is another obstacle, because due to the high number of injuries and staff shortages, staff cannot invest the hours normally needed to treat a serious traumatic injury. He said: “If this happened in [another country], this kind of operation would take 12 or 15 hours, but we do not have this luxury of time in the war.”[126]

Dr. Rose described a 16-year-old boy who had died from severe burn injuries:

It would be difficult to say if we would be able to save him if we had more capacity, but we definitely didn’t have the ability to carry out the management I would as a plastic surgeon in the UK. We didn’t even have the proper dressing we needed to cover him.[127]  

For burn victims, Dr. Rose said they lacked not only the proper dressing, but also enough saline to clean wounds.

Overcrowding in Functioning Hospitals

Parents of children who had been injured and acquired a disability described the chaos they encountered when bringing their child to one of the few remaining functional hospitals in Gaza. They described waiting several hours or longer before receiving medical attention. Tahani Abu Masir, mother of 9-month-old Ahmed, shared her experience getting his head and leg injuries treated:

As soon as we reached the hospital, it was chaotic. The hospital was full of people, everybody was screaming, everybody needed help…. Even after his surgery, there was no place for us, we stayed in the lobby.[128]

Leila Al Kafarna recounted “hours of suffering” for her son Malek when he could not receive immediate assistance following a traumatic amputation of his left arm:

My son was on the floor, he was losing blood and his entire body started shaking, his mouth was shaking, and at that moment, I started to scream for help, screaming at health professionals: “I am losing my son, please anyone help him.” They [the medical staff] had a shortage of everything, including gauze and medical staff, so many people around us were also injured and needed help. Most had lost a leg or an arm, and there were even bodies around us with no heads attached. I saw people who had considerable parts of their face blown away.[129]

After three hours, Malek was taken for surgery, but in the absence of supplies, they could only stop the bleeding. His mother said: “They didn’t have enough places or beds and covers for all the injured people.”[130]

Khuloud and her daughter Sara, a 9-year-old whose hip and legs were seriously injured, were referred to the European Hospital since there was no space in Al Shahd Aqsa Hospital, where they first took her. However, Khuloud said they could not go because the Israeli army had closed Salah al-Din Road, blocking passage that way. Receiving only painkillers for Sara, they waited for one-and-a-half week alongside other injured patients in the hospital’s yard, which at the time was a sanctuary for displaced people.

Eventually, Khuloud was able to take Sara to Egypt and then to Türkiye, where Sara underwent surgery twice.[131] 

According to Dr. Seema Jilani, the inability of the healthcare system to provide children with adequate medical treatment for urgent injuries, such as traumatic amputations, was also partly due to the high volume of patients and need to triage:

One day, a one-year-old child was brought in with both his right arm and right leg blown off. His diaper was all bloody and the flesh was hanging from his injuries. In [other countries], this boy would have been taken directly to an operating room. But since there were more life-threatening injuries than his, the orthopedic surgeon just applied a tourniquet to stop the bleeding.[132]

The high volume made it impossible for doctors to treat everyone with adequate care. Dr. Rose described:

You cannot continue to care for everyone. It is a constant battle. There were people we intended to get back to the operating room, but we could never quite keep up.… There was so much coming through the door. Even if we worked all night, all day, we were never able to keep up.[133]

Dr. A.G. said hospitals in Gaza have been unable to also provide any kind of regular treatment to children with disabilities or chronic health conditions, including due to overcrowding. “They can die simply due to lack of space in the hospital,” he said. “Keep in mind that children who had a disability prior to the war have also acquired new disabilities due to lack of access to health care or injuries.”[134]

The use of hospitals as shelters for displaced people further contributed to overcrowding, Dr. Rose said:  

The first thing that shocked me when I got there was the huge number of internally displaced people living on the hospital grounds. … [Families were] everywhere, in corridors and stairwells. As you walk through the hospital, on both sides, you see tents erected with carpets and sheets, some people sleeping on stairs. You see families of three or four children and grandparents. It’s quite shocking.[135]

Inability of Hospitals to Provide Children Necessary Treatment

The decimation of Gaza’s healthcare system, the extreme shortage of resources, and the arbitrary constraints on humanitarian assistance allowed into Gaza have forced doctors to make agonizing decisions. An MSF program director said as an example that they must choose between “sedating a patient in order to intubate them and save their life, or treating a seizure, as the same medication is needed.”[136]

Dr. Haytham Ahmed, an emergency medical physician at Nasser hospital, observed in January that Gaza’s healthcare system could not provide injured children and children with disabilities or chronic health conditions with the necessary treatments and rehabilitation—especially given the impacts of Israel’s attacks and blockade.[137] In April, MSF reported that the absence of a functional health system had resulted in numerous avoidable amputations and lost limbs.[138]

Dr. Rose, the plastic surgeon, spoke about the inability of Gaza’s health care system to provide children who have acquired a disability with the reconstructive surgeries they need:

There is one plastic surgeon in all of Gaza. He and I could do reconstructive surgeries in principle, but they take four or five hours in regular settings. In a hospital in Gaza, they would take even longer because of the lack of personnel and assistance….  You would have to spend lots more time to prepare. There would only be two of us [in Gaza], whereas at home [in the UK], there would be at least four of us and a scrub team of three or four nurses.[139]

“We had to make decisions to not allow one patient to occupy a whole day,” she said. At the rate patients were arriving, “if we had given one person the full day required, it would have had a detrimental impact on four or five other patients.”[140]

She said the closure of the Rafah crossing in May had made the situation worse. “None of the EMT [emergency medical technicians] are coming in, and more casualties are coming in.”[141]

Dr. Ana Jeelani, a pediatric orthopedic surgeon, spoke about “a cohort” of children and adults who had been seriously injured and acquired a disability who did not have access to the treatment they needed:

Some of them had been displaced from other hospitals, their wounds were infected; some had external fixators on longer than what was needed; many needed limb reconstruction surgeries they couldn’t receive.

And yet there is no access to reconstruction. Physical therapy and mobility aids, such as crutches or wheelchairs, are in short supply. Children who have acquired a disability due to sustained injuries need proper nutrition so their bones can heal, clean water so their wounds don’t get infected, monitoring as they grow.[142]

She raised concerns that due to lack of access to adequate treatment, including reconstructive surgeries and rehabilitation, children who have been injured and acquired a disability at a young age will be susceptible to developing further disabilities as they grow.[143]  

According to Humanity & Inclusion, significant damage has been inflicted upon critical rehabilitation and mental health and psychosocial support services and infrastructure, including to the Sheikh Hamad bin Khalifa al-Thani Hospital for Rehabilitation and Prosthetics, the first facility specialized in installing prosthetic limbs and providing rehabilitation in Gaza.[144] Humanity & Inclusion also noted that health care and rehabilitation services had already “experienced damage and destruction in previous wars and continue to be under operational and structural duress due to the closure imposed by Israeli authorities since 2007.”[145] Human Rights Watch documented in 2020 that children in Gaza who lost limbs had difficulty getting and replacing prosthetic and assistive devices due to the Israeli government’s closure of Gaza.[146] As of January, according to Dr. M. G., there were no rehabilitation programs left in Gaza.[147]

Lack of Essential Medicines for Children

Relatives of children who have a disability or a chronic health condition said that since October 7, their children have often been forced to forgo or otherwise ration medication, taking it in amounts or ways without a physician’s recommendation to extend its supply. Israel’s blockade and attacks have created serious shortages of medical equipment, supplies, and medication. Frequent bombardments have also made it dangerous and difficult for people to go to pharmacies, hospitals, and other health facilities to obtain medication and necessary medical equipment, even when available.

Amid the general shortage of medical supplies and medicines, a representative of Medical Aid for Palestine said in January 2024 that the organization was unable to provide medications to children with disabilities.[148] This remained the case as of August 7, 2024.[149]

Dr. Jilani described that during her two-week mission at the Al-Aqsa hospital she observed that children with chronic health conditions were unable to get necessary treatment:

When I was doing rounds in pediatric wards, I saw a 3-year-old immunocompromised patient who was clearly getting more ill and didn’t have access to medication to boost his immune system. He was having difficulty breathing and, because breathing took so much effort, he was also having difficulty eating.

Another patient, approximately 4-years-old, has cystic fibrosis, and similarly, they were unable to receive the medication they needed and were admitted to the hospital for respiratory infection and difficulty breathing.[150]

The hospital had run out of morphine and was unable to provide adequate pain medication to dying children. “We had to treat them on the floor,” Jilani said. “There was no bed, no dignity even in death.”[151]

With respect to the right to health during armed conflicts, the Office of the UN High Commissioner for Human Rights has said that states have obligations to the population under their effective control to fulfill all minimum core obligations to the right to health, including access to essential medicines.[152]

Closures of al-Rantisi Pediatric Hospital

Two families with children with disabilities reported that, prior to October 7, their children received regular treatment at al-Rantisi Pediatric Hospital in Gaza City. Following the blockade, that hospital faced difficulties providing regular treatments due to fuel and medication shortages. It ceased functioning in November 2023, after Israeli forces ordered the hospital evacuated before bombing it.[153]

Bader, a 15-year-old boy with hemophilia, a condition where blood does not clot properly, used to receive regular injections of Factor IX for treatment at al-Rantisi.[154]

He was injured on the morning of October 14, in an attack on Deir al-Balah, where his family had fled to from their home in Al Sabra neighborhood, Gaza City, after Israeli army leaflets ordered residents of northern Gaza to head south.[155] His sister said at least 15 others were killed in the strike, including their cousins, ages 6 and 17. For months since then, Bader has been unable to receive medication he needs to effectively stop the bleeding; as of February 15, he was experiencing internal bleeding in his joints. His sister shared photos of large, fist-sized, dark purple bruises on his legs.[156]

“Every day, my dad goes to the hospital, risking his life,” she said. “And every day, they [the doctors] tell him there is no treatment” available for Bader. She reported that Bader was finally evacuated to the UAE in late March and is receiving treatment.  

Since the start of the hostilities, Raisat and her 12-year-old nephew, Fadi, have been unable to access medications for their health conditions.[157] Fadi, who has cystic fibrosis, can no longer obtain pancreatic enzymes—a medication for people with cystic fibrosis, which is on WHO’s List of Essential Medicines—that he had previously received every month at al-Rantisi hospital.[158] In April, the Ministry of Health in Gaza issued a referral for Fadi for treatment abroad stating that the treatment he needs is not available in Gaza.[159] Raisat also has a disability and is a breast cancer patient. Like Fadi, Raisat has lost access to medicine necessary to treat her health condition, in her case hormone therapy, a widely prescribed breast cancer treatment.[160] As of August 20, Raisat and Fadi were both still in Gaza and did not have access to their medication.[161]

Unavailability or Unaffordability of Medication for Children

Wesam Hammad, the uncle of Muhammad, a 5-year-old with cerebral palsy, said their family could not obtain Muhammad’s required medication, including important anti-convulsant and anti-epileptic medications that he is supposed to take—and had previously taken—twice per day. “It’s been a week since he last had it,” Hammad said in December. “I am so scared he will have muscle spasms. I would buy it regardless of the cost if I could just find it.”[162] As of April 3, Hammad continued encountering challenges obtaining medication for Muhammad, because it was either unavailable or prohibitively expensive when available.[163]

After October 7, Ghazal, a 14-year-old with cerebral palsy, had to stop intensive physical therapy and missed a scheduled procedure that would have helped with her mobility.[164]

Dr. Ahmed Shahin said that his son Osman, a 16-year-old with cerebral palsy, was having more frequent convulsions because he did not have regular access to the anti-epileptic and anti-convulsant medication that he had taken twice per day before October 7. He believed the only reason his son survived the situation before the family left Gaza on November 16 was because he is a pediatrician and could personally attend to his son’s needs, including by obtaining the necessary injections through his connections and administering them.[165]

Early Intervention Shortages

Representatives from Palestine Children’s Relief Fund (PCRF) and Medical Aid for Palestine said the Israeli military operations in Gaza had made it impossible for them to continue with their regular, non-emergency programs, including specific ones that provided support and services to people with disabilities, and that they were focusing on emergency support. A PCRF representative said they feared that Palestinians with disabilities and chronic health conditions would die because of inadequate access to specialized care. Referring to the general inability to treat people, the representative said: “We are not able to respond to individual cases, no organization is.”[166] This remained the case as of August 7, 2024.[167]

Early intervention treatments that can provide significant, positive long-term effects on a child’s life and development are also lacking in Gaza. For example, Dr. Jeelani, the pediatric orthopedic surgeon, described the inability of the healthcare system to provide children with treatable conditions such as clubfoot with early intervention, including surgeries. There are no clubfoot specialists in Gaza or sufficient time to properly treat the condition, which involves weekly casting and recasting the foot to strengthen it before putting it in a brace for five years. Such braces have not been made in Gaza since the only site producing the braces was damaged and shut down and the only person trained to produce them at the site had been killed.[168]  

Dr. Jeelani said that three out of four children casted during her two-week medical mission were about 2 months old; the fourth child had started casting in Al-Shifa hospital but had to stop the treatment after October 7. Dr. Jeelani was concerned that, without treatment, those babies will not be able to walk. “I was able to cast them, they responded well, but now I’ve left and there is no one there to do the casting,” she said. “There is no brace to make. They will end up with disabilities.” After leaving Gaza, Dr. Jeelani acquired boxes of braces to send to Gaza, but she said this was impossible due to the closure of the Rafah crossing.

She said she also saw other children with developmental conditions and disabilities who needed medical care in Al-Aqsa Hospital, but that there was generally no treatment being provided to these children. “Health care is overloaded with acute cases.”[169]   

When children with developmental conditions and disabilities cannot access health care, rehabilitation, and early intervention programs, their conditions may become more complex or they may acquire further disabilities. 

Evacuations

Israel controls who can leave Gaza to get medical treatment for injuries sustained from the hostilities or for any chronic condition. Gaza Ministry of Health data indicates that over 95,500 people have been injured since October 7.[170] That number does not include people in Gaza with a disability or chronic health condition who need ongoing medical care.

According to the Ministry of Health in Gaza, 25,000 Palestinians in Gaza are in need of medical treatment abroad.[171] The number of those who have been able to evacuate for treatment reached 4,895 as of July.

Of those, many were being evacuated to Egypt, whose healthcare system has limited ability to treat their conditions. Layan, the 12-year-old who had her leg medically amputated in December after her evacuation to Egypt, highlights the inadequacy of health care there. On April 4, she developed fourth-degree bedsores—the most severe type of pressure ulcer and can be life-threatening—due to lack of access to physiotherapy and prosthetic.[172] Heals Palestine, a non-profit organization, evacuated Layan to the USA for treatment in July 2024.

Since May 7, when Israeli forces closed the Rafah crossings as part of its military operations against Rafah, Palestinians faced further difficulties to be evacuated for medical care, leaving tens of thousands of Palestinians in need of urgent medical care unable to receive treatment in Gaza or abroad.[173]

Unique Risks for Children with Disabilities during Attacks, Evacuations, and Forcible Transfers

According to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), as of August 7, 1.9 million people were internally displaced, amounting to 90 percent of Gaza’s population.[174] Civilians typically flee their homes during armed conflict to avoid fighting or reach safer areas, on the orders of a party to the conflict to evacuate for lawful security or military reasons, or because a party to the conflict unlawfully forcibly transfers them.[175] Human Rights Watch previously documented the severe difficulties civilians with disabilities face when fleeing buildings that Israeli forces attacked during fighting between 2009 and 2014, as well as their need for help to reach safety.[176]

Under the Fourth Geneva Convention applicable to occupied territory, a party to the conflict may not forcibly transfer the civilian population in whole or in part, unless required by the security of the civilians affected or for imperative military reasons.[177] 

Evacuations and the war crime of forced displacement disproportionately affect people with disabilities.[178] According to the International Committee of the Red Cross, when international humanitarian law permits such evacuations, “all possible measures must be taken in order that the civilians concerned are received under satisfactory conditions of shelter, hygiene, health, safety and nutrition and that members of the same family are not separated.” [179]  In this regard, the specific needs of persons with disabilities must be taken into account when evaluating what is satisfactory from their perspective.”

The CRPD requires governments to take “all necessary measures” to ensure the safety and protection of people with disabilities, such as by providing necessary transportation and accommodation. In June, the UN Commission of Inquiry found that Israeli forces did not offer assistance to those who were unable to evacuate due to age, illness or disability or other status.[180]

Children with disabilities face unique risks during fighting and displacement. They are less able to flee attacks; lack access to assistive devices, including those needed to flee; and risk being abandoned during flight.[181] They also have greater needs for basic services, such as health care, WASH facilities, and education. These vulnerabilities may be compounded by experiences of stigma, abuse, and psychological harm.[182]

A December 2023 discussion paper by the special representative to the secretary-general for children and armed conflict specifically addressed the unique risks facing children with disabilities. It found that children with disabilities “are at an elevated risk, not only of enduring grave violations, but also of experiencing more detrimental consequences of these violations in comparison to their peers.”[183]

Families of children with disabilities whom Human Rights Watch interviewed described difficulties in following evacuation orders and fleeing attacks. Heavy destruction made it extremely difficult to use wheelchairs and other assistive devices. The lack of electricity has stopped elevators from functioning, making it extra difficult for families of children with certain physical disabilities who live in high-rise buildings to leave their homes.  

Lack of Effective Advance Warning and Adaptable Evacuation Procedures

The laws of war provide that warring parties give effective advance warning of attacks affecting civilians, unless circumstances do not permit.[184] Where the Israeli military did not provide such warnings, children with disabilities were exposed to higher risks during Israeli airstrikes and other attacks. In the following cases, in which families of children with disabilities described strikes on their homes or neighborhoods, they said there were no warnings prior to the attacks.

Ghazal, 14

Hala Al-Ghoula, mother of Ghazal, a 14-year-old girl with cerebral palsy, said that an Israeli airstrike struck their home in Al-Shujaiya neighborhood, Gaza City, and destroyed nearly all of the family’s possessions, including Ghazal’s orthotic shoe, wheelchair, and another device she used at night. As the attacks intensified, the family fled south. Ghazal’s mother and father took turns carrying Ghazal, but they quickly tired. Hala Al-Ghoula said:

Most of the time, Ghazal would tell me, “Mama, it’s over, leave me alone and run away. You should leave me in the street.” It was one of the worst days of my life, with a very difficult feeling that can never be described. I was confused: whether to stop while we were under bombardment or to walk and leave Ghazal.[185]

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Orfat, 14

Orfat, 14, also lost his wheelchair when, according to his mother, his home in Zeitoun neighborhood, Gaza City, was hit in an attack. His mother, a single mother of six children, managed to secure a wheelchair from neighbors to move with Orfat to Rafah.[186]

Name Withheld, 14

A. J. 27, uses a wheelchair. His father has quadriplegia, his sister has a visual disability, and his 14-year-old cousin has a mobility disability. A.J. said his family did not follow the October 13 order to flee to the south nor the automated messages he got on his phone in the middle of the night instructing him to go south, since they had no way to do so with so many family members who have a disability. “I called the Red Cross and told them that we are people with disabilities and that we need help to evacuate, but they said that they were unable to help,” A.J. said.

On November 13, after the ground invasion by Israeli forces, A.J. and his family fled south, with A.J.’s 14-year-old cousin sitting on his lap. He said they had to walk 10 kilometers to Nuseirat. He said that Israeli military checkpoints along Salah al-Din Road were particularly difficult for people who use wheelchairs to navigate:

I put my cousin on my wheelchair, we held white flags and tried to cross the checkpoint on Salah al-Din Road. There was lots of sand. The Israeli army used the sand to build lots of ups and downs as part of their checkpoints, like small mountains of sand. I can usually roll my own wheelchair, but this time, it was impossible because of the sand, so another cousin was pushing me with my 14-year-old cousin on my lap. We fell twice. And no one else helps you, everyone is trying to survive the checkpoint.[187]

Osman, 16

Dr. Ahmed Shahin said it was difficult to carry Osman, his 16-year-old son with cerebral palsy, whenever they had to flee a new bombardment of their residential neighborhood in Gaza City:

We experienced hell every day. For example, one day, Israelis attacked a house in the neighborhood and the blast shattered all the windows in our house. Since the attack was so close and unexpected, we ran out of our house carrying Osman, and it’s not easy to carry him, especially while running. We ran that day for like half a kilometer to an area we thought would be safer, but it wasn’t safe. The Israeli army attacked that area as well, and we fled again.[188]

When the family decided to flee south, Osman’s wheelchair ultimately did not make leaving much easier. Dr. Shahin said:

Fleeing to the south was extremely difficult for my family, especially because of Osman. We first left by car, but due to the destruction, we had to leave our car behind. We then rented a horse and put Osman on a cart that was pulled by the horse, but after five kilometers, we also had to give up on the cart and continue on foot. It was hard because even though we had Osman’s wheelchair, there were potholes everywhere and lots of destruction. We were all sick after this journey, but Osman especially. He had a fever and was vomiting; he was sick for more than 10 days.[189]

In the cases examined by Human Rights Watch, Israeli forces do not appear to have taken into account the specific risks faced by people with disabilities, including their ability to flee attacks.

Human Rights Watch in November published its findings on the difficulties people with disabilities experienced fleeing attacks in Gaza and that the Israeli military’s October 13 order to all civilians in the northern Gaza Strip to evacuate to the south did not take into account the needs of people with disabilities, many of whom were unable to leave.[190] Human Rights Watch found that the order disproportionately exposed people with disabilities to the dangers of the hostilities and did not ensure they would be provided with proper accommodation and satisfactory conditions.

The failure of the Israeli military to provide adaptable evacuation procedures for children with disabilities who have been forced by attacks from their homes or temporary residence violates their rights under the CRPD. This has increased their likelihood of additional injury or even death.

Conditions in displacement

All children and their families that Human Rights Watch interviewed have been displaced, living in schools or in tents in makeshift camps. They all described conditions of severe overcrowding and poor hygiene, and lack of access to basic services, including sanitation.

Ghazal, 14, who has cerebral palsy, can only use the toilet or shower if her mother or sister are present to help her.[191] According to a water, sanitation, and hygiene technical advisor at Oxfam, as of January there were 500 people per toilet and 3,000 people per shower in southern Gaza.[192]

Several interviewees could not find diapers needed by a child with disabilities in their family. Wissam struggled to find and, if available, afford diapers for his nephew Muhammad, 5, who has cerebral palsy: “I need diapers for him, and I just cannot find his size. I’ve been searching all around, but even if I find it, it will cost me 50 shekels [US$14] to buy 36 diapers.”[193]

Dr. Ahmed Shahin said there were several days when Osman ran out of diapers and had to use towels instead.[194]

Loss of Parents and Caregivers

For children with disabilities, losing parents, other caregivers, and support networks is especially difficult because many of these children may need additional support compared to other children. For instance, as documented in this report, some children with disabilities need extra support to flee attacks. Moreover, because children with disabilities often experience social isolation, discrimination, and stigma, their immediate caregiver often acts as their advocate to ensure access to basic rights, such as food, health and education.[195] Thus, losing those caregivers, in addition to the trauma it brings, also harms their basic rights.

As of August 2024, according to the United Nations, at least 19,000 children in Gaza have been orphaned or otherwise found themselves alone without an adult to care for them.[196] Dr. Ana Jeelani, the child orthopedic surgeon, said she regularly saw children at Al-Aqsa Hospital who had no parents and were being cared for by strangers. She recounted seeing a 6- or 7-year-old boy in a wheelchair and with a fixator (metal frame) on his leg; his family had been killed, so the patient in the next bed was watching over him.[197]

The UN special representative on children and armed conflict, in the December discussion paper, highlighted that children who have been separated from caregivers during attacks or displacement are at higher risk of being killed or seriously injured.[198]

Nour, 14

The parents, brother, one sister, and a sister-in-law of Doaa, 35, and Nour, 14, who has Down syndrome, were killed in an Israeli airstrike on their home in Khan Yunis on December 3, according to Doaa. Nour was seriously injured. Now, Doaa is the sole caregiver of Nour, and she described the impact:

Whenever Nour sees other children with their parents, she turns to me and asks me: “My mom and dad used to do that with me as well. Who will do that for me now?” and I tell her, “I will do that for you. I will always take good care of you.” But my answer upsets her, and she says, “But it’s just you.”

Sometimes she starts crying and calling out for her mama and baba [dad]. Some days, before she goes to sleep, she tells me she hopes to see them in her dreams. One night, I heard her say, “Oh mama and baba, I am so sad you both left me. Both of you! Why did you both leave me?”

Doaa also said it is difficult for her to take care of Nour. “I used to take care of her before as well, but I wasn’t the one tracking her health needs and I don’t know much about it.”[199]

Muhammad, 5

Wesam Hammad, 25, currently takes care of his 5-year-old nephew, Muhammad, whose father, an emergency nurse, was killed in an attack. Hammad said: “Before we left Jabalia, my brother told me: ‘If I die, the responsibility is on you to take care of my child.’” He added that it is difficult to fulfill that responsibility due to lack of medicine, lack of the specific food that Muhammad needs, and their constant displacement.[200]

Anguish from Leaving Family in Gaza

Several parents who left Gaza with only their injured child spoke about the anguish they have felt being separated from their other children. Leila Al Kafarna, who left Gaza with her son Malek (who had a traumatic amputation) on December 19, has two other children, 7 and 14, she had to leave behind in Gaza with her 84-year-old husband because the evacuation permit was only for Malek and herself:

My children cry every time I call them. They are very scared, and they keep repeating that people are being killed in Gaza and begging me to bring them. Hearing their cries is heartbreaking because I cannot save them. My husband is very old; he has heart problems, diabetes, and prostate and kidney problems. He is very tired and cannot take care of the kids.[201]

Leila also described the impact on Malek, “He acts strong in front of me, but I do see his pain and how much he misses his siblings.”[202]

As of September, Leila was still in the UAE and had not been reunited with her children or husband.

Impact of Israeli Government Blockade on Children with Disabilities

After October 7, the Israeli government cut off essential services, including water and electricity, to Gaza and blocked the entry and distribution of humanitarian assistance, including food, water, and medicine, to the civilian population.

The Fourth Geneva Convention provides that the occupying power has the duty of ensuring food and medical supplies to the population.[203] Warring parties must allow and facilitate the rapid and unimpeded passage of humanitarian relief for civilians in need. They may not arbitrarily refuse to allow humanitarian assistance actions. They are also required to “permit the free passage of all consignments” of essential food, clothing and medicine, “intended for children under fifteen, expectant mothers and maternity cases.”[204]

Israeli officials have publicly stated that humanitarian aid to Gaza would be conditioned either on the release of hostages held by Hamas or on the elimination of Hamas.[205] However, Human Rights Watch has found that Israel’s effective blockade of Gaza constitutes collective punishment of the civilian population and the use of starvation as a method of warfare.[206] These are grave breaches of the Fourth Geneva Convention and customary international humanitarian law, and amount to war crimes.

Israel’s severe restrictions on access to humanitarian aid and services has been particularly harmful to children. Among other things, this has resulted in a sharp rise in the number of children suffering from acute malnutrition.[207]

This is especially true for children with disabilities who need specific support services and goods, including medication, specific food, assistive devices, hygiene products, and accessible sanitation. Israel’s decision to cut off electricity to Gaza soon after October 7 has imposed particular hardships on people with disabilities who require electricity in order to use certain medical equipment, blenders to blend food, chargers for devices such as hearing aids, power wheelchairs and other assistive devices that require electricity, and elevators needed to evacuate buildings before Israeli airstrikes.

Israel has an obligation under the CRPD to take “all necessary measures” to ensure the safety and protection of people with disabilities during armed conflict. This would entail, among other things, ensuring people with disabilities have access to the means necessary for their survival, including food, water, medication, health care, and assistive devices, all of which have mostly been absent in Gaza due to the blockade.

Impact of Starvation as a Method of Warfare on Children with Disabilities

Israeli forces have been using starvation of the civilian population as a method of warfare.[208]

In March UNICEF reported that 31 percent children under 2 in northern Gaza “suffer from acute malnutrition” and that 4.5 percent of children in the north suffer from “severe wasting,” the most life-threatening form of malnutrition.[209]  Also, in March, WHO officials reported “children dying of starvation” in both Kamal Adwan and al Awda hospitals in northern Gaza.[210] On April 3, Oxfam said people in northern Gaza have been forced to survive on an average of 245 calories a day, “less than a can of fava beans,” since January.[211] 

Save the Children confirmed that 27 children died from starvation and disease in April.[212] As of September 16, 38 Palestinians, the majority being children, have died of malnutrition and dehydration in hospitals, according to Gaza’s Health Ministry.[213] Also in June, the WHO stated that 8,000 children under 5 have been diagnosed and treated for acute malnutrition, including 1,600 children with severe acute malnutrition.[214] UNRWA stated that more than 50,000 children of all ages required treatment for acute malnutrition.[215] According to the WHO, only two stabilization centers for severely malnourished patients were able to operate because of insecurity and lack of access.[216]

While there is no official data on the number of children with disabilities among the children who have died or are acutely malnourished, existing research demonstrates that children with disabilities are in general at a higher risk of malnutrition.[217]

In March, Reuters news agency reported finding 10 seriously malnourished children—including Isra, a 5-year-old girl who has quadriplegia and epilepsy—during a visit to al-Awda Health Centre, Rafah.[218] Photographs and videos showing signs of acute malnourishment in Fadi al-Zant, a 6-year-old boy with cystic fibrosis, lying in a bed at Kamal Adwan Hospital, northern Gaza, were posted on social media and by Reuters and other media outlets in mid-March.[219] Media outlets and social media have also reported that several children with disabilities have died from starvation-related complications, including malnutrition and dehydration, including Yazan al-Kafarna, 12, who had cerebral palsy and died on March 4.[220]

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Malnutrition can also have serious physical and cognitive impacts, which can lead to a disability.[221]

Children with Disabilities Needing Specific Food

All relatives of children with disabilities interviewed by Human Rights Watch expressed having difficulties acquiring adequate food for their families. Dr. Ahmed Shahin said his son Osman, who uses a gastrostomy feeding tube, lost seven kilograms between the beginning of the hostilities and November 16 (when they were able to leave Gaza), because the family lacked access to both the specific foods he needed, such as vegetables, and electricity to blend his food.[222]

Wesam Hammad had great difficulties securing food for his 5-year-old nephew Muhammad, who has cerebral palsy and is lactose and gluten-intolerant and can only eat blended food. He said:

Most of his food should be fruits and vegetables, which is what I try to buy. But all I can find and afford are oranges. The problem is that he cannot

chew, so we need to break down the food for him. Everything is very expensive.[223]

Suhair, a single mother of six, including two children with disabilities, said she is unable to secure any additional food apart from the canned food she receives twice a day in the school where she and her family were displaced. “I don’t know how I or my children will survive,” she said, adding that she is afraid of health complications due to lack of access to fresh food, including sources of protein such as chicken or fish.[224] 

Raisat—aunt of 12-year-old Fadi, who has cystic fibrosis—and her family have had to eat much less due to the unavailability and unaffordability of food. She said:

There is no food or drink, we live on cans of cheese and beans, thank God. The prices of everything have increased by up to 70 percent…. We eat one meal in the morning and some cheese in the evening.[225]

Raisat herself also has a disability and is a cancer patient. Her 85-year-old mother uses a wheelchair, has diabetes, and is on dialysis. Raisat said that her family already lived in poverty before October 7, relying on charitable assistance from others, but that the current displacement has made obtaining adequate food and health care even more difficult.[226]

Several representatives of humanitarian organizations confirmed their inability to provide food for children on special diets or even to reach them. In January, a PCRF representative said they can only provide baby formula and thus cannot respond to the needs of children with specific diets.[227] As of August, the PCRF continued to face difficulties providing special food items to children with disabilities in Gaza due to Israel’s military’s restrictions on aid.[228] Medical Aid for Palestine said the special food items they had in storage ran out quickly, and since then, they have been unable to find and provide those in need with specialized food items:

Assistance is barely coming in: a quarter of the population is at risk of famine. Under these circumstances, people with disabilities and [people in vulnerable situations] suffer the most. When you speak about food, it’s hard to support people who need a specific diet and medical assistance.[229]

A staffer at an UN agency corroborated these challenges, saying that the conditions imposed by Israeli authorities have prevented them from implementing a dignified humanitarian response, including toward children and adults with disabilities.[230]

Impact of Lack of Access to Water on Children with Disabilities

Starting October 9, the Israeli government has maintained a policy to deny adequate access to water to civilians in Gaza, which has led to deaths from starvation and dehydration, and outbreaks of waterborne diseases. This has been done through restricting the entry of water entering Gaza through water pipelines; cutting electricity and restricting fuel that is required for to operate water, sanitation and hygiene (WASH) facilities; destroying and damaging WASH infrastructure; obstructing the ability of Gaza’s WASH authorities, and humanitarian actors, to make repairs; and blocking and restricting the entry of WASH-related supplies into Gaza. The authorities’ denial of adequate water to the civilian population is a war crime.

The Office of the UN High Commissioner for Human Rights has said that states that are party to the International Covenant on Economic, Social and Cultural Rights involved in armed conflicts jeopardize and violate their obligations to the right to health when they threaten or restrict access to safe and potable water and adequate sanitation.[231] In December, UNICEF reported that children in Gaza have access to only 10 percent of their normal water supply.[232] In just one week in mid-December UNICEF recorded 3,200 new cases of diarrhea in children per day.[233] In January, UNICEF reported that displaced children and their families in Gaza were unable to maintain the necessary levels of hygiene to prevent disease, which it attributed to the lack of safe water and sanitation, with many resorting to open defecation.[234] UNICEF reported in May that  9 out of 10 children under 5 in Gaza are having one or more infectious diseases and that levels of acute watery diarrhea are 20 times higher than typical.[235] 

In June, UNICEF raised the alarms that the very few functioning hospitals were unable to adequately treat disease outbreaks because they were so focused on responding to the high number of injured patients.[236]  A month later, on July 19, UNICEF reported that waterborne illnesses were spreading further, causing skin diseases and rashes on children.[237] In July, Gaza’s Ministry of Health and the WHO announced that the highly infectious vaccine-derived poliovirus had been identified at six locations in sewage samples collected by UNICEF.[238] By August 23, both the Palestinian Ministry of Health and the World Health Organization had confirmed the first case of polio in an unvaccinated 10-month old child in Gaza.[239]

Healthcare facilities also cannot operate without clean water, presenting significant challenges to conducting surgeries, providing treatment for disease and infections, and treating wounds for the thousands of wounded individuals in the Gaza Strip.

UNICEF had previously reported that children with disabilities generally face additional difficulties accessing water, sanitation, and hygiene compared to other children.[240]

The families of children with disabilities interviewed by Human Rights Watch said they experienced limited availability and access to clean drinking water. Some reported that their child with a disability also faced difficulties with accessing adequate sanitation, including necessary hygiene products, such as diapers.

Without access to safe and sufficient water, several interviewees said they began using groundwater for personal and domestic use, including drinking, even though, according to UN OCHA, it is almost entirely “unfit for human consumption.”[241]

Dr. Ahmed Shahin’s family did not have enough water, and clean drinking water is especially important for his 16-year-old son Osman, who has cerebral palsy and needs to be fed by a tube. He told Human Rights Watch how they managed:

We had a filter for the tap water, but for this filter to work, you need electricity, which we didn’t have. So, at the beginning of the war, we would boil the tap water, especially because of my son Osman. However, a week later, even this water was cut off. We then had to find different ways to get water. There was a house we had to walk to that had groundwater; but we could never get as much as we needed for personal and hygiene use.[242]

When they fled south, they all became sick, including due to unclean water, but Osman suffered the worst and longest with a fever and vomiting. Dr. Shahin said Osman was sick for more than 10 days.

A.J., 27, who uses a wheelchair and fled with his 14-year-old cousin who also has a mobility disability, explained that it is harder for both children and adults with disabilities to physically access adequate water. “Because I am in a wheelchair, I am not able to go out and look for water,” he said. The water they get from the school where they were staying has been scarce: they received only one liter per person, and there were days when they received none.[243] As of August, A.J. had fled Rafah for Deir al-Balah where he has been living with his family in a tent.[244]

The mother of 14-year-old Ghazal, who has cerebral palsy, worried that the lack of access to clean water would increase Ghazal’s risk of infections and diseases. She said Ghazal has had diarrhea more than once since their displacement to Rafah.[245] At the time of our interview in December, Wesam Hammad, the uncle of 5-year-old Muhammad, who has developmental disabilities, said his nephew had been sick for a week with vomiting and diarrhea due to the conditions of their displacement and lack of access to water.

Raisat described family members struggling with vomiting and diarrhea due to their lack of access to clean drinking water and healthy food. At the time of our interview, Raisat lived with her 12-year-old nephew Fadi and 11 other relatives, including 4 other children, in a tent. They could not afford bedding, covers, or winter clothes, and Raisat said the cold gave Fadi chest pain.[246] Dr. Seema Jilani explained that children with cystic fibrosis are at higher risk of respiratory illnesses during the flu and cold season, as colder weather can exacerbate cystic fibrosis symptoms.[247] As of August, Raisat and Fadi had been displaced for the fifth time and were living in a tent in Deir al-Balah, where they continue to struggle to access water.[248]

Research has shown that children with disabilities, especially if they do not have access to adequate nutrition, are at elevated risk of experiencing serious infections, including diarrhea, fever, and symptoms of acute respiratory infection.[249]

Psychological Harms to Children with Disabilities

Months of “violence, displacement, starvation and disease on top of nearly 17 years of a blockade have caused relentless mental harm to children in Gaza,” according to Save the Children.[250] UNICEF estimated that almost all of the 1.2 million children in Gaza are in need of mental health and psychosocial support, twice the figure compared with before October 7.[251]

Children whose mental health has been severely harmed may acquire a psychosocial disability. This impact is aggravated for children with disabilities who fear inability to flee attacks, abandonment, and have concerns about how their situation may put family members at risk.

Health and humanitarian professionals in Gaza told Human Rights Watch that for children with disabilities, constant fear, loss of family members, displacement, hunger, lack of access to health care and proper hygiene, and loss of assistive devices caused severe harm in their mental health.  A teenage girl with cerebral palsy and several relatives of children with disabilities relayed personal accounts of these experiences.

Acquiring a disability without adequate support can be extremely difficult for children. Dr. Haytham Ahmed said physical injuries, especially burns and amputations, take an enormous toll not only on a child’s physical health, but also on their psychological well-being.[252] Speaking about children who have had their limbs amputated and are unable to receive the reconstructive surgery and rehabilitation they need, including mental health support, he said: “We are talking about children who are dealing with extreme trauma, horrific fears, and physical harms. They will need therapy and psychosocial support for life.”[253]

Dr. Jeelani, the child orthopedic surgeon, similarly said:

The psychological trauma is massive and it’s not quantifiable. Children are resilient to physical injuries: with adequate treatment, they bounce back really well compared to adults. But the psychological aspect of it, I don’t know how you quantify it in a place like Gaza. It’s not just their own injuries and lack of treatment, but they are seeing things they shouldn’t see. There are children there who had told me they have seen 10 bodies of [Palestinians killed in Israeli attacks], they shouldn’t be seeing this kind of stuff.[254]  

Khuloud observed changes in her daughter Sara, 9, whose hip and legs were seriously injured: 

Her own injury and everything she witnessed, all of that hit her psychologically. I can see a change in her. Sara is getting more nervous, pulling her hair and biting her nails, and her voice has gotten really loud since the attack happened. She is loud with me, raises her hand, and then she feels bad about it. She is not the same child.[255]

Ghazal, the 14-year-old with cerebral palsy, said:

From the day the war broke out, they destroyed what was inside us. They demolished my house and my room, which held all my memories. They took everything that helped me live, like my devices, my boot, and my wheelchair. How can I go back to how I was without all this?[256]

Caregivers of children with disabilities are impacted, too, which is important given their important role not only in caring for, but also advocating for their children with disabilities’ access to health and assistive devices, among other basic needs. The blockade and the ongoing attacks have everyone on edge. Dr. Shahin described how emotions ran higher at night. “Everything was difficult, but it was Jahannam [hell] when it got dark,” he said. “No water, no food, no electricity, people are hungry, thirsty, everyone is under stress, irritated.”[257]

Raisat—the aunt of 12-year-old Fadi, who has cystic fibrosis—felt unsafe everywhere and described her fear, including from hearing projectiles:

The feeling that you have, you wish to be dead, this is not a life to be living. We have not had a proper night of sleep since the war started. The constant destruction, constantly seeing dead people, this is not something that anyone can handle….  The sound of missiles and shrapnel alone gives me enough horror and nightmares. You are not safe anywhere. If you are near a school, near a hospital, you are not safe anywhere.[258]

Raisat said she dreads the prospect of having to flee once more, especially because of the challenges faced by her mother, who uses a wheelchair, and her older father who also has mobility difficulties. “I fear the Israeli army will drop leaflets and will attack Rafah,” she said. “I don’t know what our fate will be in the coming days.”[259]

Mental health and psychosocial support services, which were already difficult to access prior to the current hostilities, have grown even scarcer since the start of the Israeli military’s attacks on Gaza. Medical Aid for Palestine, Palestine Children’s Relief Fund, and UNICEF are all unable to provide mental health services and psychosocial support.[260] “Psychologists and social workers are themselves in a survival mode,” said a UNICEF representative.[261]

Furthermore, the mental health of children with disabilities is uniquely impacted by their fears that their disability will affect their and their family members’ ability to flee and by the additional impediments they face to accessing services. Ghazal wondered what to do, now that her devices are destroyed: “I need my devices to help me walk…. Now I am unable to get up and when I want to move, my mother or sister must help me. But I am afraid: what if they ask us to leave Rafah. How do I leave?”[262]

Dr. A.G. said that in the hospitals, the lack of access to anesthesia and pain-relieving medicines has caused significant suffering and emotional distress.[263]

The psychological challenges for people with disabilities are not new: Human Rights Watch in 2020 reported that children and adults with disabilities in Gaza experienced additional psychological distress because of their inability to flee, fears of future attacks, and how to survive them.[264]

Another psychological impact of the recurring hostilities and crises is the loss of education. Nearly 90 percent of schools in Gaza have been damaged or destroyed, and hundreds of thousands of students have been out of school for the 2023-2024 school year, including the children with disabilities whose families Human Rights Watch interviewed.[265]

Ghazal, as one such child, dreams of returning to school. “I wanted to complete my education and continue my life normally,” she said. “I was one of the outstanding students in school.” Without prompting, many families shared that their child or children with disabilities loved going to school and their favorite subject. Access to education is crucial because safe and protective environments like schools can provide a sense of normalcy essential to children’s development and psychological well-being.

International Humanitarian and Human Rights Law Relating to Children with Disabilities

International humanitarian law and international human rights law provide protections for children with disabilities that are applicable during armed conflict.

International humanitarian law

Under international treaty provisions, notably the Fourth Geneva Convention and Protocol I to the Geneva Conventions, and customary international humanitarian law, children affected by armed conflict are entitled to special respect and protection.[266]

Under the Fourth Geneva Convention, parties to a conflict are required to take all necessary measures to ensure “children under fifteen, who are orphaned or are separated from their families as a result of the war, are not left to their own resources.”[267] All parties to a conflict must allow the free passage of relief intended for certain groups, including children under 15.[268]  Occupying powers such as Israel must “facilitate the proper working of all institutions devoted to the care” of children in occupied territory.[269]

Protocol I and Protocol II specifically provide for the privileged treatment of children during armed conflict and requires parties to a conflict to provide children “with the care and aid they require, whether because of their age or for any other reason.”[270] Protocol I reiterates the rights of children to medical care and to temporary evacuation where the child’s health or medical treatment needs require it.[271]

International Human Rights Law

The Convention on the Rights of the Child (CRC) applies to all children, including children with disabilities, and guarantees their rights to survival; develop to their fullest potential; and be protected from harmful influences and abuse. It also makes specific reference to children with disabilities, outlining the principle of non-discrimination and the special efforts states should make to realize the rights of children with disabilities.[272]

In situations of armed conflict, the Convention on the Rights of the Child directs states to “undertake to respect and ensure respect of rules of international humanitarian law which are relevant to the child and ensure protection and care of children who are affected by the armed conflict.”[273]

The Convention on the Rights of Persons with Disabilities (CRPD) affirms the rights of people with disabilities to equality and non-discrimination; freedom from violence and abuse; and to the highest attainable standard of health, among other rights.[274] Article 11 calls for states to take “all necessary measures to ensure the protection and safety of persons with disabilities in situations of risk,” including armed conflicts, in accordance with their obligations under international humanitarian law and international human rights law.[275] UN Security Council Resolution 2475 reaffirms this duty by obliging all parties to an armed conflict to take measures to protect civilians with disabilities.[276]

Everyone, including children with disabilities, has the right to enjoy the highest attainable standard of mental health, including psychosocial services.[277]

In areas under its effective control, Israel is obligated to ensuring the provision of services designed to minimize and prevent further disabilities, including access to rehabilitation.[278]

In its concluding observations on Israel from October 9, 2023, the UN Committee on the Rights of Persons with Disabilities, called on Israel to identify and prevent:

[T]he risks and harms faced by persons with disabilities during military operations and [identify] their requirements in that context, [to prevent] attacks on and damage to infrastructure and civilian premises, including hospitals, rehabilitation centers and ambulances, and [to protect] schools from military attacks.[279]

The UN High Commissioner for Human Rights has stated that parties to the International Covenant on Economic, Social and Cultural Rights—which obligates states to respect, protect, and fulfill the rights to food, water, adequate sanitation, and health including during armed conflicts—should pay particular attention to the treatment of persons rendered vulnerable by conflict, including children and people with disabilities.[280] 

Recommendations

To the Government of Israel

Protection and Safety of Children with Disabilities

·       Refrain from using explosive weapons with wide area effects in populated areas, the use of which raises serious concerns that attacks are likely to indiscriminately harm civilians, including children, and civilian objects in violation of international humanitarian law.

·       Take all necessary measures for the protection and safety of children with disabilities in Gaza as obligated by international humanitarian law and international human rights law, including the Convention on the Rights of Persons with Disabilities (CRPD).

·       Specifically consider the protection and safety of children with disabilities in military operations in accordance with international humanitarian law, including by raising awareness and sensitization at all levels of the military on the particular risks and harms to people with disabilities and their needs during military operations.

·       Provide effective advance warning of attacks, unless circumstances do not permit, in accessible and inclusive manners and formats, to allow people with disabilities sufficient time to evacuate.

·       Do not unlawfully displace civilians in violation of international humanitarian law. In case of evacuation orders, take into account the needs of people with disabilities, many of whom are unable to leave without assistance. Ensure that evacuation areas are capable of providing for the needs of people with disabilities.

·       Facilitate the evacuations of children with disabilities and their families to voluntarily receive medical care elsewhere, while ensuring their right to return to Gaza.

·       End the closure regime and permit free movement of people and goods to and from Gaza, subject to the restrictions permitted under international law, recognizing the   acute risks to children with disabilities caused by the longstanding closure of Gaza. 

·       Dismantle all forms of systematic domination and oppression against Palestinian children with disabilities, including in Gaza, and ensure they have access to rights equal to Israeli citizen children with disabilities.

International Court of Justice Orders 

·       Comply with provisional measures ordered by the International Court of Justice to protect Palestinians in Gaza from genocide.

Access to Humanitarian Aid

·       Stop obstructing aid—particularly food, including those items needed by children on a special diet, water, medicine, assistive devices, and fuel—from entering Gaza by fully opening its crossings, urgently opening additional ones, and not placing unjustified restrictions that prevent humanitarian goods from entering Gaza.

·       Eliminate the “dual-use” label on medical-related supplies, assistive aids, and accessible technology like eyeglasses, wheelchairs, walkers, canes, hearing aid, and other assistive devices needed by people with disabilities, the restriction of which invariably has a disproportionate negative impact on civilians compared to any military advantage.

·       Restore access to water and electricity.

·       Ensure the protection of aid workers, including by ending attacks on humanitarian convoys, humanitarian workers, and officials in Gaza responsible for protecting and distributing aid. 

·       Ensure aid can reach all parts of Gaza and that civilians can safely receive it, including by ending attacks on civilians gathered to collect aid.

·       Support the provision of sustainable, timely, appropriate, inclusive, and accessible assistance to civilians with disabilities, in line with UN Security Council Resolution 2475 (2019).

Access to Health Care

·       Ensure the right to the highest attainable standard of health.

o   Do not conduct unlawful attacks on medical personnel, facilities, and transports as well as on the wounded and sick, or obstruct access to health care, particularly as a punitive measure.

o   Comply with all non-derogable components of the right to health, including ensuring the equitable distribution and access to health facilities, goods, and services on a non-discriminatory basis.

o   Provide access to essential medicines, particularly those defined as such by WHO’s Action Programme on Essential Drugs.

·       Support the provision of mental health and psychosocial support services to children, and ensure they reach and are accessible to children with disabilities.

Reparations

·       Develop and implement a reparations program, on the basis of meaningful and effective consultations with victims, that includes targeted reparations for children who have acquired a disability and children with a pre-existing disability, including those with psychosocial disabilities, who have been harmed as a result of violations of international human rights or humanitarian law. Ensure they have access to free, quality, and rights-respecting medical, psychosocial, and mental health care services, including rehabilitation for the acquired disability and assistive devices.

To All Parties to the Conflict in Israel and Palestine

·       Abide by the requirements of international humanitarian law, including the provisions on the methods and means of conflict and the laws of occupation.

·       Do not carry out deliberate, indiscriminate or disproportionate attacks on civilians and civilian objects.

·       Respect the special protection afforded to medical personnel, facilities, and transports.

·       Take all feasible measures to ensure that civilians under the control of a warring party are protected against the effects of attacks.

To All Governments

·       Publicly condemn violations of international humanitarian law and grave international crimes.

·       Use arms embargoes, targeted sanctions, including travel bans and asset freezes, and other forms of leverage to press Israel to comply with their obligations under international humanitarian law and international human rights law, including the CRPD.

·       Press Israel to comply with international humanitarian law provisions on the provision of humanitarian assistance, including to urgently approve and facilitate the entry into Gaza of all medical necessities, including anesthetics and other critical and essential medicine, including for children with disabilities, and assistive devices.

·       Press Israel to ensure child medical and mental health specialists can enter Gaza without restrictions.

·       Publicly support the work of the International Criminal Court in its ongoing Palestine investigation. Uphold the court’s independence and publicly condemn efforts to intimidate or interfere with its work, officials, and those cooperating with the institution.

·       Support foreign domestic investigations and prosecutions under the principle of universal jurisdiction, as relevant and appropriate, of those credibly implicated in serious crimes in Gaza.   

·       Address long-standing impunity by Israeli authorities and Palestinian armed groups for serious crimes under international law. Plan and support efforts to survey, clear, and destroy explosive remnants of war from the ongoing hostilities in Gaza.

·       Collaborate with the Palestinian and Egyptian authorities to identify children, including those with pre-existing disabilities, who need medical treatment abroad and facilitate their evacuation for treatment. 

·       Facilitate access to trainings and education, including through support and scholarships, for medical, social, and mental health staff from Gaza.

To States Providing Arms/Military Assistance to Israel

·       Suspend military assistance and arms sales to Israel so long as its forces commit  violations of international humanitarian law with impunity.

·       Enforce domestic legislation limiting the transfer of arms and military assistance for violations of international human rights and humanitarian law.

To UN Security Council Members

·       Urgently press Israel to protect both children and adults with disabilities in Gaza, in line with its obligations under international humanitarian law, international human rights law, including the CRRPD, and Security Council Resolution 2475.

To the UN Secretary-General and the Special Representative on Children and Armed Conflict

·       Ensure the inclusion of children with pre-existing and acquired disabilities as part of its efforts to monitor and report on grave violations against children in Palestine (and in all armed conflicts), in particular killing and maiming, attacks on schools and hospitals, and denial of humanitarian access.

To Donors and Humanitarian Organizations

·       Cooperate to ensure that children with different types of disabilities are included in all humanitarian responses in Gaza to provide them equal access to food, including specific food items needed because of their disability or health condition, water, medical care, psychosocial services, rehabilitation, and education.

·       Cooperate to ensure humanitarian assistance includes programming to address long-term mental health impacts and trauma.

Acknowledgements

This report was researched and written by Emina Ćerimović, associate director in the Disability Rights Division.

Open-source research was conducted by Sophia Jones, open-source researcher in the Digital Investigations Lab. Milena Ansari, Israel and Palestine assistant researcher, provided research assistance and support for this report, including open-source research.

This report was edited by the senior editor in the Disability Rights Division and Samer Muscati, acting deputy disability rights director. Tom Porteous, deputy program director, and James Ross, legal and policy director, provided programmatic and legal review respectively.

The following Human Rights Watch staff provided specialist reviews: Mark Hiznay, associate director, Mary Wareham, deputy director, and Belkis Wille, associate director, in the Crisis, Conflict, and Arms Division; Matt McConnell, researcher in the Economic Justice and Rights Division; Bill Van Esveld, associate director in the Children’s Rights Division and acting Israel/Palestine director in the Middle East and North Africa Division; Bridget Sleap, senior researcher on the rights of older people in the Disability Rights Division; Balkees Jarrah, associate director in the International Justice Program; Nadia Harman, researcher in the Refugee and Migrants Rights Division; Heather Barr, associate director in the Women’s Rights Division; Sam Dubberley, director, in the Technology, Rights and Investigations Division; Abier Almasri, senior assistant researcher in the Middle East and North Africa Division; Omar Shakir, Israel and Palestine Director, Eric Goldstein, former deputy director in the Middle East and North Africa Division; Milena Ansari, Israel and Palestine assistant researcher, Adam Coogle, deputy director in the Middle East and North Africa Division; Niku Jafarnia, Bahrain and Yemen researcher; Hiba Zayadin, senior Syria and Jordan researcher; Louis Charbonneau, United Nations director; Claudio Francavilla, associate EU advocacy director; Yasmine Ahmed, UK director; Sarah Yager, Washington director; and Farida Deif, Canada director.

Subhajit Saha, senior coordinator in the Disability Rights Division, provided editorial assistance as well as production assistance and support. Christopher Choi, acting associate in the Disability Rights Division, assisted with desk research. The layout and production were done by Ivana Vasić, graphic designer; Travis Carr, publications officer; Jose Martinez, administrative officer; and Fitzroy Hepkins, senior administrative manager.

Taurai Maduna, Christina Curtis, and Ifé Fatunase, in the Multimedia division, and Abier Almasri in the MENA division were instrumental in the creation of the audiovisual materials accompanying this report. Yousef Mashharawi and Ahmad AL lulu conducted the videography for this report.

Human Rights Watch expresses its gratitude to non-governmental and humanitarian organizations who shared their knowledge and expertise as well as the frontline workers who are working in Gaza to provide critical health care amid the ongoing hostilities and for generously sharing their experiences on the ground.

We offer our deepest thanks to Kim Samuel and The Samuel Family Foundation for their generous support, unwavering partnership, and steadfast commitment to ensuring the voices of children with disabilities in Gaza are amplified.

Most importantly, Human Rights Watch thanks the children and families whose courage and dignity in sharing their stories and experiences made this report possible. We recognize the acute trauma they and their communities were experiencing at the time of the interviews and continue to experience.