As reported in a recent New York Times article, a group of doctors, nurses, and paramedics reported a cluster of what was claimed to be gunshot wounds to the heads of children in the crowded battle space of Gaza. No reasonable military mission scenario would allow such targeting. Though not explicitly stated, the piece strongly suggests the culprits were soldiers of the Israeli Defense Force (IDF). In a world where everyone has a camera, live on-the-scene images of injuries and death shock the consciousness. Witness the recent photos of the dead body of Yahya Sinwar; a significant and apparent defect in his skull is visible. Such proof of death and injury, though shocking, is critical when the spread of disinformation has never been easier.
In criminal law, intent (mens rea) is a person’s mental state when they commit a crime. The proof of intent is complex, and although some actions strongly suggest intent, doubt can remain. War involves the intentional killing of others, but International Humanitarian Law recognizes the right of lawful combat that results in killing. Separate from war, murder is the killing of a human being with malice aforethought. In war, murder is still possible when the killing occurs absent justification or excuse. In every war, the unintentional killing of civilians is the consequence of indirect fire, and the allowable quantity of death by this method distinguishes the point between collateral damage and war crime.
Included in the New York Times piece are three images purported to be side-view X-rays of children’s skulls and necks. A radiopaque structure resembling a boat tail bullet can be easily seen in these radiographs. A boat tail is a type of rifle bullet tapered at the end, resembling the shape of a sailboat. Upon closer examination, it became quickly apparent to many people with expertise in medicine and ballistics that the X-rays may have been doctored or specifically chosen to claim intentional targeting of civilian children.
Understanding why these X-rays are so suspicious requires understanding how such images are generated and further understanding ballistics – the scientific study of projectiles and firearms and the motion and impact of bullets. Finally, what compelled healthcare workers, including physicians, to post false or misleading accounts of these injuries? Why would physicians advance the idea that such injuries were the result of strategic intent on the part of the IDF?
The acceleration of electrons creates an X-ray by inducing them to release electromagnetic radiation. Once generated, these X-rays are passed through the body until they collide with a special photo-stimulable imaging plate. This new plate replaces the old-style conventional X-ray film. The human body comprises tissues of varying densities, with bone and dental enamel being the densest and air the least. When an X-ray encounters bone, some X-ray beam is blocked, and the created shadow appears as a whiter image on the plate. Very little of that X-ray beam is blocked when an X-ray beam passes through the air, and the displayed image appears black.
A bullet consists of material like lead or steel denser than anything naturally occurring in the body. Bullets appear as bright white objects. The denser the object, the whiter it appears. Significantly, any X-ray image of the body basically compresses the 3-dimensional body into a 2-dimensional image. Physicians skilled in X-ray interpretation understand the general relationship of natural structures within the body and can reconstruct 3-dimensional relations from a 2-dimensional flat image.
When an image is observed on an X-ray that is not a naturally occurring structure within the body, one is unable in a single image to know if that object is on the body, in the body, or behind the body. We need at least two separate X-ray images offset by 90 degrees to pinpoint the location of that object. The New York Times story produced only single images and when asked for more, the reply was that the images were too gruesome for view. When a bullet passes through the skull, the resulting penetration fractures the skull bone and creates a hydrostatic pressure wave, causing tissue injury easily visible on X-ray images. No fracture or any other injury can be seen in the supplied images.
In the images from the New York Times story, a bullet appears to rest within the skull and neck of a child. The damage inflicted by any bullet is dependent on the mass and the speed of the bullet. As a rule, the higher the kinetic energy, the higher the wounding capacity and lethality. Any Increase in mass and velocity of the bullet will result in a higher kinetic energy. However, for practical purposes, there is always a limit on how high the mass and the speed can be for any weapon to remain portable.
The IDF uses the 5.56 x 45 mm NATO cartridge. The bullet fired from this cartridge is very light and designed to inflict damage by fragmentation within the tissue (terminal ballistics). To attain this, this light bullet must strike the target at a very high velocity. The bullet has different variants, each designed to fulfill an intended purpose (antipersonnel, barrier penetration, tracer, etc.).
The muzzle velocity of the 5.56 mm round, when fired from the standard rifles used by the IDF, like the American-made M4 or Israeli-made IWI X95 (Tavor), depending on the barrel length and the variant of bullet, is between 2,900 and 3,100 f/sec. The capability of the bullet to fragment decreases significantly when the bullet speed decreases below 2,500 ft/sec, which is approximately 150 and 200 yards of travel in the air. However, a bullet traveling at that speed is very likely to still pass through an adult human torso and not get lodged within the tissue.
The bullets in the radiograph showed minimal to no deformation and were lodged in the soft tissue. This would suggest they were likely fired from a long distance, possibly at least 500 yards. However, beyond 300 yards, the accuracy of such a light bullet, like the 5.56 mm, is seriously compromised and can be affected even by minimal wind. While it is true that accurate shots with 5.56 x 45 mm bullets are still possible at long distances, this requires a very steady platform and exact calculations of distance to target and wind speed and direction. These conditions are far from those encountered in a war scenario, where rapid target acquisition while avoiding being shot at tends to be the norm.
Although it is technically possible to shoot a small target the size of a child’s head at a distance for the bullet to remain lodged within the soft tissues, to do this consistently, as the authors suggest, is extremely unlikely, if not impossible particularly when considering multiple other variables, like the fact that a child is doubtful to remain stationary, wind conditions in an urban environment, and the expectation of incoming fire.
If one assumes by an extraordinary circumstance that a fired bullet should lodge within the head of a child, it cannot be known with certainty who fired that bullet and why. The IDF uses the standard NATO rifle that shoots a 5.56-round. Hamas favors an AK rifle, but some variants also fire a 5.56 bullet. Also, on occasion, Hamas has been able to obtain NATO-style weapons. So-called celebratory gunfire is the shooting of a bullet directly into the air in celebration. Such practices are known to occur in parts of the Middle East. In the US, celebratory gunfire is generally illegal because it can be associated with severe injuries, including head injuries from falling bullets.
For the healthcare worker in Gaza, politics are prevalent. Israel has just barred six medical NGOs from operating in Gaza. One of these groups, the Palestinian American Medical Association, had members in the New York Times report. No one disputes that children are being injured and killed in Gaza. Still, healthcare workers ceased to be effective advocates for health and safety when they speculated or lied about the nature of injuries they claimed to encounter. Medical accounts of injuries and deaths in an active war zone are critically valuable in making sense of the risks to the civilian population in the battle space. Medical personnel risk acting as purveyors of disinformation when departing from impartial accounting.
One cannot imagine the shooting of innocent children is in the strategic interest of the IDF. Further, the ballistic facts make such targeting impossible. The medical profession must be unbiased. The banning of medical NGOs might be the final straw after a series of pernicious NGO-generated propaganda. In this war, the patients are the losers. The media, with a publish now, retract later approach, has created confusion in the desperate pursuit of a story. Now, more than ever, a calm and impartial appraisal on the part of healthcare and the media is desperately needed. When the war ends, as it indeed will, an accounting of the facts by combatants, including Hamas and its enablers, will seek to identify any crimes committed, and punishment will follow crime accordingly.
Joel B. Zivot, MD, FRCP(C), MA, JM is an associate professor of anesthesiology and surgery and is a practicing anesthesiologist, intensive care physician, and expert in bioethics and law. Zivot has written extensively on several subjects related to the intersection of medicine and war. Zivot is a recognized expert in opposition to physician participation in the death penalty.
Horacio Hojman, MD, is a trauma surgeon and Chief of Trauma and Acute Care Surgery in academic medical practice. In addition to his surgical training, Hojman is an expert in bioethics and chairs an ethics committee. Hojman served as a medical officer in an anti-terrorist unit in Argentina.
