Why Gaza's Death Toll Is Probably Higher Than Reported

Palestinians look at damages as smoke rises from a fire among the debris at the site of an Israeli strike on an area designated for displaced people, in Rafah in the southern Gaza Strip, May 27, 2024 (photo)

Starvation, unsanitary conditions, and bodies beneath the rubble have almost certainly contributed to a death toll much higher than what we have heard.

by Liat Kozma and Wiessam Abu Ahmad, reposted from Ha’aretz

The fatality numbers in the Gaza Strip over the past seven months are appalling. According to the UN Office for the Coordination of Humanitarian Affairs, over 34,000 people have been killed and over 77,000 have been wounded, with another 11,000 trapped under the rubble of their homes and considered missing.

But this is just part of the picture. We believe that the morbidity and fatality numbers in Gaza are actually higher. Our conclusion is based on comparisons with the public health challenges in refugee camps immediately after the 1948 war and a familiarity with epidemiological data in general. We believe that the scope of the killing, as well as the incidence of illness and deaths due to a lack of basic sanitary conditions, food and medical care, demand an urgent public debate in Israel.

A read through historical documents raises several important parallels, as well as differences, mostly to the detriment of the current situation. Then as now, hundreds of thousands of people had to leave their homes with no ability to return.

In 1948, around 700,000 refugees were dispersed to the West Bank, Gaza and Arab countries. In the West Bank, a population of 400,000 absorbed 300,000 refugees, whereas the 80,000 people of Gaza took in three times as many refugees. In the current war, the siege on Gaza and the closure of the border with Egypt over the winter forced around 1.5 million people into Rafah, an area with a population normally one-tenth this number. The people are so tightly packed together that the implications are life-threatening.

Palestinians look at the destruction after an Israeli strike where displaced people were staying in Rafah, Gaza Strip, Monday, May 27, 2024. (photo)

In 1948 and 1949, international humanitarian organizations strove to prevent what was deemed a danger to the lives of all people in the region, not just the refugees. One type of intervention was the prevention of famine by the provision of flour, oil, sugar and dried fruit, as well as milk for children (financed by UNICEF). These products, low on proteins and vitamins, were considered adequate for the short period until the sides reached a settlement, which, as we know, they never did.

But, as noted by the International Red Cross, already on October 7, food deliveries to Gaza were cut sharply and without precedent compared to previous rounds of fighting. The destruction of what little agricultural land there was has left Gazans with no local alternatives.

What led to rising food prices and poverty at the beginning of the war turned into real famine in the following months, initially in northern Gaza and now for over 2 million people. There are reports of families subsisting on livestock feed, insects and normally nonedible plants – poor nutrition that is unfit for human consumption. Not enough aid trucks are getting in, so the need for food and basic products is far from being met. The airdropping of provisions is inefficient, sometimes even deadly, and some of the aid falls into the sea.

With no monitoring system and the destruction of the police force in Gaza, gangs seize the aid packages and sell them to the needy at a high price. So food still is not reaching the starving population and the number of deaths due to hunger is rising.

Palestinians search for food among burnt debris in the aftermath of an Israeli strike on an area designated for displaced people, in Rafah in the southern Gaza Strip, May 27, 2024. (photo)

According to the UN Office for the Coordination of Humanitarian Affairs, around 31 percent of children under 2 in northern Gaza and around 10 percent in Rafah are suffering from severe malnourishment. The numbers of dead due to starvation are not yet known, but it is clear that many people are suffering irreversible damage. People who subsist on weeds and livestock feed for months will not survive long.

The second intervention in 1948 was the realization that without clean water and adequate sanitary conditions, waterborne and insect-borne epidemics will be fatal for all people of the region. For this reason, organizations made it a point to provide drinking water and vaccines, while implementing quarantines during disease outbreaks and frequently spraying pesticides. The latter proved toxic in the long run, but in the short run it saved the refugee concentrations from lethal epidemics.

Palestinians travel in a donkey-drawn cart loaded with their belongings as they flee Rafah due to an Israeli military operation, in Rafah, in the southern Gaza Strip, May 28, 2024. (photo)

Today, however, clean water is virtually unavailable to most residents of Gaza. Aid organizations estimate that all waterborne disease are already rife in Gaza. According to the World Health Organization, the number of people sick with preventable diseases may soon exceed the number of those falling victim to military attacks. A lack of clean water and medical care may lead to an outbreak of lethal waterborne diseases, even cholera.

WHO spokesperson Margaret Harris told The Guardian that already in early November, diarrhea among children in camps in Gaza was over 100 times the normal level. Without available treatment, this may lead to dehydration and even death; severe diarrhea is the second most common cause of death among children under 5 around the world. Upper respiratory tract infections, chickenpox and painful skin diseases are also on the rise.

In addition, areas with a large number of dead bodies and body parts scattered in the open are an ideal environment for bacteria and the outbreak of disease via air, water, food and animals. In conditions of high population density, it is virtually impossible to implement quarantines or spray pesticides and, lacking a proper sanitation infrastructure, it is also impossible to stymie waterborne disease.

Palestinians line up for food during the ongoing Israeli air and ground offensive on the Gaza Strip in Rafah, Jan. 9, 2024. (photo)

A third intervention in 1948 was the setting up of clinics and hospitals. The aid organizations expanded existing hospitals, established new ones and opened clinics in camps and refugee centers. None of this is happening today. The shelling and the long siege have totally destroyed Gaza’s health system. Hospitals that are still partially functional are suffering severe shortages of medical equipment and medication.

Already six months ago, reports began to circulate about cesarean sections and amputations without anesthesia. The health system not only is incapable of providing routine treatments and preventative care, it is also unable to provide emergency treatment. The continuing absence of these three types of treatments – routine, preventative and emergency – may lead to an exponential rise in death rates, illness and even epidemics. Chronic diseases – including heart disease, kidney disease, cancer and diabetes – are not being treated, and it’s very doubtful whether chronic patients have survived the war; only a few fortunate ones have made it out of Gaza to receive medical care in Egypt.

Against this backdrop, Israelis’ silence is costing lives. Even those who warn about a “second Nakba” must acknowledge that the damage of the current war has already far outdone that of the first Nakba. And each passing day – with its shortage of food, proper sanitary conditions and available medical care – further increases the human cost. Any debate on the war must take into account its far-reaching, long-term implications for everyone who lives in this land.

Liat Kozma is a historian and Wiessam Abu Ahmad is a biostatistician at the Hebrew University of Jerusalem.

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