Letter to President Biden, Vice President Harris, and Dr. Jill Biden
OPEN LETTER FROM AMERICAN MEDICAL PROFESSIONALS WHO SERVED IN GAZA
The Honorable Joseph R. Biden
President of the United States
The White House
Washington, DC
United States of America
The Honorable Kamala D. Harris
Vice President of the United States
The White House
Washington, DC
United States of America
July 25, 2024
Re: American physicians’ and nurses’ observations from the Gaza Strip since October 7, 2023
I’ve never seen such horrific injuries, on such a massive scale, with so few resources. Our bombs are cutting down women and children by the thousands. Their mutilated bodies are a monument to cruelty.
Dr. Feroze Sidhwa, trauma and critical care surgeon
I saw so many stillbirths and maternal deaths that could have been easily prevented if the hospitals had been functioning normally.
Dr. Thalia Pachiyannakis, obstetrician and gynecologist
Every day I saw babies die. They had been born healthy. Their mothers were so malnourished that they could not breastfeed, and we lacked formula or clean water to feed them, so they starved.
Asma Taha, pediatric nurse practitioner
Gaza was the first time I held a baby’s brains in my hand. The first of many.
Dr. Mark Perlmutter, orthopedic and hand surgeon
Dear President Joseph R. Biden, Vice President Kamala Harris, and Dr. Jill Biden,
We are forty-five American physicians, surgeons, and nurses who have volunteered in the Gaza Strip since October 7, 2023. We worked with various nongovernmental organizations and the World Health Organization in hospitals throughout the Strip. In addition to our medical and surgical expertise, many of us have a public health background, as well as experience working in humanitarian and conflict zones, including Ukraine during the brutal Russian invasion. Some of us are veterans of the United States Armed Forces. We are a multifaith and multiethnic group. None of us support the horrors committed on October 7 by Palestinian armed groups and individuals in Israel.
The Constitution of the World Health Organization states: “The health of all peoples is fundamental to the attainment of peace and security and is dependent on the fullest cooperation of individuals and States.” It is in this spirit that we write to you.
We are among the only neutral observers who have been permitted to enter the Gaza Strip since October 7. Given our broad expertise and direct experience of working throughout Gaza we are uniquely positioned to comment on several matters of importance to our government as it decides whether to continue supporting Israel’s attack on, and siege of, the Gaza Strip. Specifically, we believe we are well positioned to comment on the massive human toll from Israel’s attack on Gaza, especially the toll it has taken on women and children.
This letter collects and summarizes our own experiences and direct observations in Gaza. We have also provided links to a much longer and heavily cited appendix summarizing the publicly available information from media, humanitarian, and academic sources on key aspects of Israel’s invasion of Gaza. The appendix is available as a PDF file at https://tinyurl.com/gazadoctorsletterappendix. This letter can be accessed electronically as a PDF file at https://tinyurl.com/gazadoctorsletter.
This letter and the appendix show probative evidence that the human toll in Gaza is far higher than is understood in the United States. It is likely that the death toll from this conflict is already greater than 92,000, an astonishing 4.2% of Gaza’s population. Our government must act immediately to prevent an even worse catastrophe than what has already befallen the people of Gaza and Israel. A ceasefire must be imposed on both Israel and Palestinian armed groups by withholding military support for Israel and supporting an international arms embargo on both Israel and all Palestinian armed groups. We believe our government is obligated to do this, both under American law and International Humanitarian Law, and that it is the right thing to do.
With only marginal exceptions, everyone in Gaza is sick, injured, or both. This includes every national aid worker, every international volunteer, and probably every Israeli hostage: every man, woman, and child. While working in Gaza we saw widespread malnutrition in our patients and our Palestinian healthcare colleagues. Every one of us lost weight rapidly in Gaza despite having privileged access to food and having taken our own supplementary nutrient-dense food with us. We have photographic evidence of life-threatening malnutrition in our patients, especially children, that we are eager to share with you.
Virtually every child under the age of five whom we encountered, both inside and outside of the hospital, had both a cough and watery diarrhea. We found cases of jaundice (indicating hepatitis A infection under such conditions) in virtually every room of the hospitals in which we served, and in many of our healthcare colleagues in Gaza. An astonishingly high percentage of our surgical incisions became infected from the combination of malnutrition, impossible operating conditions, and lack of supplies and medications, including antibiotics. The pregnant women we treated often gave birth to underweight infants, and they were unable to breastfeed due to malnutrition. This left their newborns at high risk of death given the lack of access to potable water anywhere in Gaza. Many of those infants died. In Gaza we watched malnourished new mothers feed their underweight newborns infant formula made with poisonous water. We can never forget that the world abandoned these innocent women and babies.
We urge you to realize that epidemics are raging in Gaza. Israel’s continued, repeated displacement of the malnourished and sick population of Gaza, half of whom are children, to areas with no running water or even toilets available is absolutely shocking. It is virtually guaranteed to result in widespread death from viral and bacterial diarrheal diseases and pneumonias, particularly in children under the age of five. We worry that unknown thousands have already died from the lethal combination of malnutrition and disease, and that tens of thousands more will die in the coming months. Most of them will be young children.
Children are universally considered innocents in armed conflict. However, every single signatory to this letter treated children in Gaza who suffered violence that must have been deliberately directed at them. Specifically, every one of us on a daily basis treated pre-teen children who were shot in the head and chest.
President and Dr. Biden, we wish you could see the nightmares that plague so many of us since we have returned: dreams of children maimed and mutilated by our weapons, and their inconsolable mothers begging us to save them. We wish you could hear the cries and screams our consciences will not let us forget. We cannot believe that anyone would continue arming the country that is deliberately killing these children after seeing what we have seen.
The pregnant women we treated were particularly malnourished. Those of us who worked with pregnant women regularly saw stillbirths and maternal deaths that were easily preventable in any third-world healthcare system. The rate of infection in C-section incisions was astonishing. Women underwent C-sections without anesthesia, and were given nothing but Tylenol afterwards because no other pain medications were available.
All of us observed emergency departments overwhelmed by patients seeking treatment for chronic medical conditions such as renal failure, hypertension, and diabetes. Aside from trauma patients, most ICU beds were taken up by type 1 diabetics who no longer had access to injected insulin, due to the lack of medication and the widespread loss of electricity and refrigeration. Israel has destroyed more than half of Gaza’s healthcare resources and has killed one out of every 40 healthcare workers in Gaza. At the same time healthcare needs have increased massively from the lethal combination of military violence, malnutrition, and disease.
The hospitals where we worked were starved of basic supplies from, surgical material to soap. They were regularly cut off from electricity and Internet access, denied clean water, and operated at four to seven times their bed capacity. Every hospital was overwhelmed beyond the breaking point by displaced persons seeking safety, by the constant stream of patients whose treatment of chronic conditions had been interrupted by the war, by the huge influx of seriously wounded patients who typically arrived in mass casualty events, and by the sick and malnourished seeking medical care.
These observations and the publicly available material detailed in the appendix lead us to believe that the death toll from this conflict is many times higher than what is reported by the Gaza Ministry of Health. We also believe this is probative evidence of widespread violations of American laws governing the use of American weapons abroad, and of International Humanitarian Law. We cannot forget the scenes of unbearable cruelty directed at women and children that we witnessed ourselves.
As we met our healthcare colleagues in Gaza it was clear that they were malnourished, and both physically and mentally devastated. We quickly learned that our Palestinian healthcare colleagues were among the most traumatized people in Gaza, and perhaps in the entire world. Like virtually all people in Gaza they had lost family members and their homes. Most lived in and around their hospitals with their surviving families in unimaginable conditions. Although they continued working a grueling schedule, they had not been paid since October 7. All were acutely aware that their work as healthcare providers had marked them as targets for Israel. This makes a mockery of the protected status hospitals and healthcare providers are granted under the oldest and most widely accepted provisions of International Humanitarian Law.
We met healthcare personnel in Gaza who worked at hospitals that had been raided and destroyed by Israel. Many of these colleagues of ours were taken by Israel during the attacks. They all told us a slightly different version of the same story: in captivity they were barely fed, continuously physically and psychologically abused, and finally dumped naked on the side of a road. Many told us they were subjected to mock executions and other forms of mistreatment and torture. Far too many of our healthcare colleagues told us they were simply waiting to die.
We urge you to see that Israel has directly targeted and deliberately devastated Gaza’s entire healthcare system, and that Israel has targeted our colleagues in Gaza for death, disappearance, and torture. These unconscionable acts are entirely at odds with American law, American values, and International Humanitarian Law.
Dr. Biden, you worked with young people throughout your life. We hope and pray that you will not look away from the unspeakable horrors the youth of Gaza face today, horrors only we as Americans can end. We sincerely hope you will do everything in your power to stop what is being done to them.
President Biden and Vice President Harris, any solution to this problem must begin with an immediate and permanent ceasefire. We urge you to withhold military, economic, and diplomatic support from the State of Israel and to participate in an international arms embargo of both Israel and all Palestinian armed groups until a permanent ceasefire is established, and until good faith negotiations between Israel and the Palestinians lead to a permanent resolution of the conflict.
In the meantime, we reiterate what we wrote in our letter of July 25, 2024:
All land crossings between Gaza and Israel as well as the Rafah Crossing must be opened to unfettered aid delivery by recognized international humanitarian organizations. Security screening of aid deliveries must be conducted by an independent international inspection regime instead of Israeli forces. These screenings must be based on a clear, unambiguous, and published list of forbidden items, and with a clear independent international mechanism for challenging forbidden items, as verified by the UN Office for the Coordination of Humanitarian Affairs in the occupied Palestinian territory.
A bare minimum water allocation of 20L of potable water per person per day must be allocated to the population of Gaza, as verified by UN Water.
Full and unrestricted access of medical and surgical professionals and medical and surgical equipment to the Gaza Strip must be allowed. This must include items taken in healthcare professionals’ personal luggage to safeguard their proper storage, sterility, and timely delivery, as verified by the World Health Organization. Incredibly, Israel is currently blocking any physician of Palestinian descent from working in Gaza, even American citizens. This makes a mockery of the American ideal that “all men are created equal” and degrades our nation and our profession. Our work is lifesaving. Our Palestinian healthcare colleagues in Gaza are desperate for relief and protection, and they deserve both.
We are not politicians. We do not claim to have all the answers. We are simply physicians and nurses who cannot remain silent about what we saw in Gaza. Every day that we continue supplying weapons and munitions to Israel is another day that women are shredded by our bombs and children are murdered with our bullets.
President Biden and Vice President Harris, we urge you: end this madness now!
Sincerely and urgently,
Appendix to letter of July 25, 2024
Re: American physicians observations from the Gaza Strip since October 7, 2023
Today, the Gaza Strip is once again the most dangerous place in the world to be a child.
UNICEF Executive Director Catherine Russell, December 1, 2023
Gaza is the most dangerous place in the world to be an aid worker, as well as the most dangerous place to be a civilian.
International Rescue Committee, April 3, 2024
Tiny Gaza Is Home to Most of the World’s Hungriest People.
Wall Street Journal headline, January 22, 2024
[A]t least 108 journalists and media workers were among the more than 39,000 killed since the war began, making it the deadliest period for journalists since CPJ began gathering data in 1992.
Committee to Protect Journalists, July 24, 2024
This appendix complements the letter sent to President Joseph R. Biden and others on July 25, 2024 by American physicians who have served in the Gaza Strip. It is divided into four sections. The first explores the evidence of the likely death toll from the conflict between Israel and the Palestinians in Gaza since October 7, 2023. The second focuses on the evidence of violence deliberately directed at children and the right to learn. The third focuses on the evidence of a direct and sustained Israeli attack on the healthcare system and healthcare workers in Gaza. And the last focuses on the evidence of a direct and sustained attack on civilian infrastructure in Gaza and widespread environmental devastation.
All sections are cited with links instead of footnotes for ease of reading. Please contact Dr. Feroze Sidhwa (DoctorsInGaza@gmail.com) for with any questions or clarifications.
The likely death toll since October 7, 2023
“Conflict obviously causes deaths and injuries on the battlefield, but also health consequences from the displacement of populations, the breakdown of health and social services, and the heightened risk of disease transmission.” Deaths from military violence are usually the smaller share, and indeed civilian excess mortality in wars can be 25 times higher than deaths from violence. These so-called “indirect” deaths are driven by respiratory infections, gastrointestinal infections, and maternal and neonatal deaths. The more severe and prolonged the societal disruption the higher these deaths rise. Children under five years of age and adults over 69 years of age experience the greatest increase in mortality, and these effects often persist for two years after the fighting ends.
The Lancet, the most prestigious medical and public health journal in the world, recently published estimates from American, British, and Canadian experts on the likely toll this conflict has taken: “it is not implausible to estimate that up to 186,000 or even more deaths could be attributable to the current conflict in Gaza.” Below we summarize the available public information on deaths from military violence, malnutrition, infectious diseases, chronic diseases, and cancers. As noted above, there is probative evidence that the death toll in Gaza is many times higher than the publicly reported figure of violent deaths. We include the publicly available information from the October 7 attack by Palestinian armed groups on Israel both for completeness and comparison.
Deaths from violence
On October 7, 2023 Palestinian armed groups and individuals carried out a major attack on southern Israel, killing at least 1,123 Israelis. At least 809 were civilians (72%), including at least 40 minors, as well as 314 Israeli military and security personnel (28%). Since then, as of July 3 an additional 332 Israeli military personnel have been reported killed in Gaza, bringing the total to at least 1,455 people killed, 44.4% military and security personnel and 55.6% civilians.
As of July 24, since October 7 Israel has killed at least 39,145 Palestinians through military violence in Gaza. As of April 30, 24,686 of these bodies have been fully identified by the Gaza Health Ministry: 32% of fully identified casualties are children, 20% are women, and 8% are elderly people. An additional 10,000 bodies were estimated to be buried under the rubble of destroyed buildings on May 2. The Gaza Health Ministry’s numbers, cited above, are widely considered a reliable minimum. For example:
On November 8 Assistant Secretary of State for Near Eastern Affairs Barbara Leaf stated at a hearing before the House Foreign Affairs Committee that the true numbers of dead are “very high, frankly, and it could be that they’re even higher than are being cited.”
On February 29, Secretary of Defense Lloyd Austin confidently cited these numbers in testimony before the House Armed Services Committee.
The State Department cited the Gaza Ministry of Health data prior to the October 7 attacks.
Israeli intelligence reportedly uses these numbers in internal decision making and analysis.
Both the Washington Post and the Israeli newspaper Haaretz report that these numbers are generally reliable.
Public health experts at the Columbia Mailman School of Public Health, the Johns Hopkins Bloomberg School of Public Health, and the London School of Hygiene and Tropical Medicine all report that the Gaza Ministry of Health is a reliable source establishing a minimum number of dead from violence.
In the 100 days from October 7, 2023 to January 14, 2024 Israeli forces killed more than 1% of Gaza’s population. A UN ESCWA report noted that “No other armed conflict in the twenty-first century” has had “such a devastating impact on a population in such a short timeframe. To find a 100-day period with greater bloodshed, it is necessary to go back to the 1994 genocide against the Tutsi in Rwanda.”
Deaths from malnutrition
The Gaza Health Ministry only reports deaths caused directly by violence that arrive at a hospital morgue. As noted above, these are typically the smallest number of deaths in any major and protracted conflict.
Hunger in Gaza is not being caused by the unavoidable societal disruption that accompanies war. Israel is deliberately starving Gaza, as is widely acknowledged. For example:
According to Human Rights Watch, since October 7 the “Israeli government is using starvation of civilians as a method of warfare in the Gaza Strip.”
On February 12 Senator Van Hollen declared on the Senate floor that “Kids in Gaza are now dying from the deliberate withholding of food.”
On April 5, former Special Envoy for Middle East Humanitarian Issues Ambassador David Satterfield reportedly told the American Jewish Committee “there is an imminent risk of famine for the majority, if not all, the 2.2 million population of Gaza. This is not a point in debate. It is an established fact, which the United States, its experts, the international community, its experts assess and believe is real.”
On April 10, USAID Administrator Samantha Power reported to the House Foreign Affairs Committee that “USAID teams have been working day and night to address the catastrophic humanitarian crisis in Gaza, where nearly the entire population is living under the threat of famine.” She answered “yes” when asked if northern Gaza was already in famine.
World Food Programme Executive Director Cindy McCain stated on May 5 “there is famine, full blown famine in the north, and its moving its way south” in Gaza.
Both the U.S.-funded Integrated Food Security Phase Classification (IPC) and the U.S. Famine Early Warning System (FEWS) warned in March that Gaza was likely in famine.
On May 28, Stacy Gilbert, a 20-year career State Department senior advisor in the Bureau of Population, Refugees, and Migration, resigned after the input of her team to NSM-20 was overruled. “I was shocked,” she said of the report, “that it...went on to say: it is our assessment that Israel is not blocking humanitarian assistance. That is not – that is not – the view of subject matter experts at the State Department, at USAID, nor among the humanitarian community. And that was known, that was absolutely known to the administration for a very long time... The reason we’ve come to this point is because of Israel’s obstruction.”
On May 31 the FEWS reported that food delivery in May 2024 was cut in half compared to April. Because “significant amounts of food remain in storage or staging areas within Gaza” the “amount of food entering Gaza does not equate to the amount on markets or being consumed.” In June, data limitations prevented the FEWS from distinguishing between IPC Phase 4 and Phase 5 (Famine) conditions in northern Gaza. In southern Gaza Phase 4 conditions were well established. “In a scenario in which large-scale assistance is delivered, Emergency (IPC Phase 4) outcomes are likely. In a scenario in which large-scale assistance is disrupted for multiple weeks or more, Famine (IPC Phase 5) is likely. Regular, safe, and unhindered humanitarian access to deliver lifesaving interventions must be guaranteed to confidently conclude that Famine (IPC Phase 5) will be averted.”
In June the IPC warned that even if the technical definition of famine is not met or cannot be proven due to incomplete data “the situation in Gaza is catastrophic and there is a high and sustained risk of Famine across the whole Gaza Strip.”
The fact that Palestinians in Gaza are so hungry that many have died, or that this is the result of deliberate Israeli policy, should not be in dispute. However, the scale of this starvation is not widely appreciated.
According to the IPC, in December 377,000 Palestinians in Gaza were in the catastrophe phase of food insecurity and 939,000 were in the emergency phase. Death from starvation of course takes time, and it is not clear how many people in Gaza have died from starvation and its complications or how many will die in the future. Still, according to the IPC technical manual: in the catastrophe phase of food insecurity the crude death rate rises to at least 2 deaths per 10,000 people per day, and in the emergency phase the crude death rate rises to 1-2 deaths per 10,000 people per day. At these rates, the most conservative estimate that can be made is that 30,000 people have died in Gaza from starvation since December. Utilizing the far worse IPC report from March adds an additional conservatively estimated 7,786 deaths from starvation in Gaza. In total it is likely that 37,786 people have died of starvation and its compilations in Gaza since October 7.
As long as aid agencies and public health experts are denied entry to Gaza the true numbers cannot be known. However, if these estimates are accurate they will approximately match the projected estimates of 85,750 total excess deaths in Gaza by August 2024 under the epidemics and military escalation scenarios published by a joint project from Johns Hopkins Center for Humanitarian Health and the London School of Hygiene and Tropical Medicine. This is the population-adjusted equivalent of 13.3 million deaths and 26.6 million injuries in the United States.
In its June report, the IPC noted that Israel’s invasion of Rafah led to a major disruption of feeding programs that had helped stave off famine in April and May, and notes that “the number of Outpatient Therapeutic Feeding Program (OTPs) shrunk between April (102) and May (66), and many nutrition partners lost access to warehouses and supplies...” They also note that “Due to the lack of humanitarian access and insecurity, no population surveys have been conducted to measure the prevalence of malnutrition”, truly shocking given the dire situation. Despite the major data limitations, the IPC estimates that 495,000 (22.5%) Palestinians in Gaza remain in catastrophic food insecurity and another 745,000 (33.9%) in emergency food insecurity.
In its May 31 update to its reports on Gaza, FEWS reported that the death rate of 4/10,000/day in children under 5 had likely been surpassed in northern Gaza in April, and stated that “it is reasonable to infer from the inadequacy of health and nutrition interventions – including the complete absence of such services from Gaza governorate through April – that additional deaths [from malnutrition] have been unreported.” On July 9, eleven international experts declared that famine had likely spread from northern to central Gaza.
Alex de Waal, a leading historian of famine and executive director of the World Peace
Foundation at Tufts University, compared the situation to “the worst famine on the IPC record books” in 2011 in Somalia. “At its nadir, 490,000 people were in ‘catastrophe’ conditions with a larger number in ‘emergency’ conditions. An estimated 258,000 people perished over 18 months.” Somalia’s population is eight times the size of Gaza’s, yet as many Palestinians in Gaza are thought to be in the catastrophe phase of food insecurity today as Somalians were at the worst moment of the 2011 famine.
All told, it is highly likely that the death toll from starvation matches or even exceeds the death toll from violence in Gaza. We hope and pray that starvation is not already causing widespread death in Gaza, but this is wishful and dangerous thinking. Only time and careful investigation will reveal the truth. As physicians we fully agree with de Waal: “Famine is unfolding in Gaza today. We should not have to wait until we count the graves of children to speak its name.”
Deaths from infectious diseases
Malnutrition and disease conspire together to kill children, especially those under the age of 5. Beyond the huge death toll from violence and famine, the destruction wrought on Gaza’s water, sanitation, and hygiene (WASH) infrastructure and the incredible overcrowding caused by the forced displacement of the overwhelming majority of the population, combined with widespread malnutrition, is extremely dangerous. UNOSAT satellite imagery analysis found that 87% of critical water and sanitation facilities in the Gaza Governorate had been destroyed or severely damaged by January 25. Oxfam’s Middle East director Sally Abi Khalil noted on May 13, that with “the infrastructure already beyond [the] breaking point, little or no healthcare available, and widespread malnutrition this could quickly escalate into a major epidemic.” Research in the International Journal of Public Healthreported that Gaza has endured an 80% decrease in access to water since October 7. “In consequence, there is far too little water for drinking and washing—in some areas only 10% of the 15 Litres per person per day required in emergencies.” In a report entitled Water War Crimes, Oxfam concludes that “Israel has systematically weaponized water against the Palestinians in its latest assault on Gaza...” Indeed, “the Government of Israel has used water deprivation to dehumanize and ultimately threaten Palestinian lives since the 1993 Oslo Accords. This culminates, in a brutal fashion, in the current military operation in Gaza.” Gaza is likely the thirstiest place in the world: “Since the Israeli offensive began...people in Gaza have had only 4.74 litres of water per person per day for all uses...a dramatic 94% reduction in the amount of water available before. This is significantly below the internationally accepted minimum standard of 15 litres of water per person per day for basic survival in emergencies.” Five WASH “infrastructures had been taken out of service every three days” by Israeli attacks, amounting to a 1% loss of WASH capacity for Gaza every three days since October 7. By June 26 Gaza City had lost “nearly all of its water production capacity”, the “Israeli military had destroyed 100% of all water and sanitation warehouses in Gaza City and Khan Younis” and “70% of all sewage pumps and...100% of all wastewater treatment plants in Gaza” had been destroyed. If Israel’s plan to force one million or more Palestinians into the “Mawasi safe zone” the area “could become the most densely populated in the world with the potential to provide a mere 2.48 litres [of water] per person per day.”
The World Health Organization (WHO) reported on January 22 that the “burden of acute respiratory infections, diarrhea and skin infections has been particularly high, with a steady week-on-week high incidence of reported cases...” In other words, every week had higher numbers than the previous week. “The number of diarrheal illnesses reported among children under 5 years in the last three months of 2023 was about 25 times higher compared with the corresponding period in 2022.” Compounding the situation, “no meaningful public health measures for disease prevention and control could be implemented due to access constraints and lack of supplies coming into the Gaza Strip. The absence of such measures will result in unmitigated transmission of bacterial, viral, fungal and parasitic pathogens.... Surgical cases are managed suboptimally, resulting in higher levels of disability and death, including the need to prioritize life-saving amputations rather than limb reconstruction, premature discharge from hospital due [to] lack of bed availably and a high proportion of wound infections compounded with limited access to antibiotics.” As of June 16, the ReliefWeb Unified Health Dashboard reported 923,000 cases of acute respiratory infections, 527,000 cases of acute watery diarrhea and 11,000 cases of bloody diarrhea, and 92,000 cases of acute jaundice in Gaza since October 7. These numbers represent only confirmed cases and are surely a dramatic undercount.
When researchers at the Johns Hopkins Center for Humanitarian Health and the London School of Hygiene and Tropical Medicine included the outbreak of epidemics and military escalation (as is ongoing in Gaza) in their models the predicted 85,750 excess death sin Gaza by August 2024. If this scenario is realized it will mean that Israel will have killed 3.9% of Gaza’s population, and perhaps wounded another 8%. We are unaware of a similar proportion of any population being killed and maimed in 10 months of conflict since World War II.
“On May 6th,” the IPC notes in its June report, “the IDF instructed residents of southern Rafah to leave their homes and announced the expansion of the Israeli-designated ‘humanitarian zone’. Examination of the dimensions of the expanded zone revealed it to be approximately 62 km2 in area....it is estimated that the population density within the zone could exceed 28,000 person/km2. This would constitute the most densely populated area on earth...it would not be possible to provide adequate food and other essential supplies to the population within this zone...” Furthermore, “Given the projected concentration of people in the ‘humanitarian zone’, a failure to provide adequate humanitarian access or basic services could lead to a rapid deterioration and a catastrophe of unprecedented magnitude compared to the suffering already witnessed in Gaza since October.” Unsurprisingly, a “serious level of civil unrest in such a context is extremely likely. The ability to support displaced and resident people within the zone has already been degraded by high levels of destruction of WASH facilities, housing, and health facilities.” Oxfam estimates that in the Israeli-declared “humanitarian zone” of Mawasi there is one toilet for every 4,132 people (the Sphere Handbook, which sets standards of quality for humanitarian emergencies, recommends 20-50 people per toilet at maximum).
Israel is concentrating a sick and malnourished population, constituted mainly of children, onto little more than a beach with no running water or even toilets available to it. In these conditions epidemics are virtually guaranteed and will be absolutely devastating, resulting in tens of thousands more dead, most of them young children. There is absolutely no reason for the world to let this happen.
Disruption of care for chronic diseases and cancers
Cancer care has been entirely unavailable in Gaza since October 7. The previous mechanisms for referring patients outside of Gaza have broken down. Between October 7 and May 7 nearly five thousand Palestinians were evacuated from Gaza through the Rafah Crossing. Most of these evacuations were for traumatic injuries requiring complex reconstructive operations. Since Israel’s capture and closure of the Rafah Crossing on May 7 only 19 patients in need of advanced medical care have been evacuated. On July 24 Israel did reportedly agree to evacuate 250 Palestinians from Gaza to the UAE. As described in the attached physicians letter, the few functional emergency departments in Gaza are continuously overwhelmed by people seeking care for chronic diseases, ranging from type 1 diabetes to seizures to hypertension.
The WHO reported on January 22 that “About 350,000 people live with chronic diseases in the Gaza Strip. Shortages of essential medications and closures of health care facilities are increasingly impeding access for the 52,000 individuals with diabetes, 45,000 with asthma, 45,000 with cardiovascular disease and 225,000 with hypertension. Of the 178 haemodialysis machines, 63% are situated north of Wadi Gaza, severely limiting access to dialysis for the 1,100 patients who need this service to survive.”
It is unknown how many patients with chronic medical conditions have died as a result of the massive disruption of Palestinian society and Israel’s sustained direct attacks on Gaza’s healthcare system. We dare not venture a guess, but we can say with absolute certainty that it is no small number.
***
It is impossible to accurately estimate how many Palestinians in Gaza have died since October 7. As the above evidence makes abundantly clear the number is far, far higher than the 39,145 who are confirmed killed by military violence as of July 24, 2024. With the known violent deaths, the estimated ten thousand people buried under the rubble and certainly dead, a conservative estimate of 38,000 deaths from malnutrition and disease, and a conservative estimate of 5,000 deaths in patients with chronic diseases, we estimate that the current death toll is likely upwards of 92,000, agreeing quite closely with the projected estimates cited above. This represents a shocking 4.2% of all people in the Gaza Strip. These are the most conservative estimates of the death toll that can be made with the given available data as of July 24, 2024. It is highly likely that the real number of deaths in Gaza from this conflict is far higher, and without an immediate ceasefire the death toll will only continue to mount.
Evidence of Direct Attacks on Children and the Right to Learn
Forty minors, including five children age five or younger, were killed by Palestinian armed groups and individuals in the October 7 attacks. We struggle to find words for such an atrocity as the deliberate killing of forty innocent minors.
As of April 30, 7,797 fully identified children are known to have been killed by Israeli violence in Gaza. (April 30 is the last time the Gaza Ministry of Health was able to issue new categorizations for fully identified corpses in Gaza’s morgues.) This shocks us to our core, and even so we must acknowledge that this is a dramatic undercount. The true number is certainly more than double, as reported on May 1 at least 14,500 children had been killed in the Gaza finding more unaccompanied children every day.” We met many of these children in the hospitals where we served. They were referred to in the medical record by an acronym that should not exist: “WCNSF”, or “wounded child, no surviving family”. span of seven months. An unknown number of children are buried under the rubble of Gaza. As of February, Save the Children reported at least 17,000 Palestinian children had been separated from their families or orphaned, and the “number is likely much higher now, with our team in Gaza finding more unaccompanied children every day.” We met many of these children in the hospitals where we served. They were referred to in the medical record by an acronym that should not exist: “WCNSF”, or “wounded child, no surviving family”.
These numbers are so large that they require some reference to be meaningful. Many of us have worked in the horrors of the war in Ukraine, and we believe it provides a useful measure of scale. In the United Nations Secretary General’s 2023 report Children and armed conflict the war in Ukraine was the deadliest armed conflict in the world for children.
In all of 2022, in a country of 38 million people under relentless assault from a military superpower, 732 children were killed, a rate of 0.0053 children killed per 100,000 people per day. In Gaza, with an estimated 14,500 children killed in the seven months from October 7 to May 1, the rate is 3.1 children killed per 100,000 people per day. The rate of killing of children in Gaza since October 7 is 584 times higher than in Ukraine in 2022. Even if we only consider the 7,797 fully identified children who have been killed the rate of killing of children is still 314 times higher in Gaza than in Ukraine. No other conflict in living memory has killed 1.6% of the children in any territory in seven months through violence alone. This is the population-adjusted equivalent of 1.2 million children being killed in the United States, an atrocity that is simply unfathomable!
As detailed above, it is very likely that tens of thousands of Palestinians in Gaza have already died of starvation, and a large proportion of these deaths will have been in young children. There is an unusually large amount of recorded evidence of children being directly targeted by Israeli violence in Gaza (e.g. the recorded execution by sniper of 3-year-old Emad Abu al-Qura while in the arms of his 20-year-old medical student cousin Hadeel, or the killing of 6-year-old Hind Rajab, 15-year-old Layan Hamada, and the medics sent to rescue Hind). As stated in the attached letter, every signatory saw multiple children shot in the head and/or chest during their time in Gaza, usually on a daily basis. It “is notable”, found a study in BMJ Global Health, “that the proportion of women and children killed [in Gaza since October 7] would be indistinguishable if Israel were known to be indiscriminately bombing civilians.”
Beyond the killing of children lies the utter devastation of Gaza’s educational and learning systems. By January 20 Israel had destroyed every single university in Gaza, often enthusiastically and publicly. Israel’s assault on institutions of learning is so widespread that it was termed a “scholasticide” by 25 international experts and an “educide” by Israeli academic Neve Gordon. As of April 18, Israel had killed at least 261 teachers and 95 university professors in Gaza. No child in Gaza has attended school in more than nine months. Students with international scholarships have not been permitted to leave Gaza to study abroad.
Evidence of Direct Attacks on Healthcare Personnel and Facilities
Virtually all of Gaza’s acute care hospitals have been attacked and damaged. As of July 24, 20 of Gaza’s 36 hospitals are completely out of service, while 16 remain partially functional. As of March 22, 81% of Gaza Health Ministry and UNRWA primary care clinics had ceased functioning. By January 22, 59% of the hospital beds in Gaza had been destroyed, while the remaining partially functioning hospitals operated at 359% of their actual bed capacity. As of April 1, nineteen international emergency medical teams with 120 international and 500 national staff, had performed 225,000 patient consultations, performed over 13,000 emergency operations, and assisted over 900 deliveries, providing desperately needed relief to our Palestinian healthcare colleagues and much needed medical and surgical care to Palestinians in Gaza. There is significant probative evidence from a statistical study by a team of American and German researchers that Israel made no distinction between hospitals and other targets in Gaza during the first month of the attack.
As discussed in the attached letter our Palestinian healthcare colleagues are beleaguered, besieged, and demoralized. Investigative reporting has confirmed that mistreatment and truly sadistic torture – including shocking sexual violence – is in fact being widely used in Israeli detention centers against Palestinian detainees from Gaza, including healthcare personnel. Ambulance personnel were particularly cynical about their chances of surviving the war, based largely on prior experience during Israeli invasions of Gaza.
From October 7 to April 20, Israel carried out 435 attacks on medical facilities and healthcare workers, killing 723 people and detaining 118 health workers. Of the 160 Palestine Red Crescent Society ambulances in the Gaza Strip, 25 have been destroyed and 29 damaged, while 17 PRCS staff and volunteers have been killed, 35 seriously injured, and five taken by Israel. Gaza Ministry of Health ambulances have fared even worse than those of the PRCS, with 126 damaged or destroyed by April 3. As of June 26, the British charity Medical Aid for Palestinians reported that 500 healthcare workers had been killed in Gaza. “This equates to an average of two healthcare workers killed every day, with one in every 40 healthcare workers, or 2.5% of Gaza’s healthcare workforce, now dead. More healthcare workers have been killed in Gaza since October than were reported killed in all conflicts globally in 2021 and 2022 combined.”
Save the Children reports that the “rate of attacks per month on healthcare in Gaza since the beginning of the war has been higher than in any other recent conflict globally, standing at an average of 73 attacks each month,” and compares this to the next worst case: 67 attacks per month in Ukraine, a difference of 8%. These unadjusted numbers fail to capture the incredible scale of direct Israeli attacks on healthcare personnel and infrastructure in Gaza.
The rate of attacks on healthcare per day per 1,000,000 people is 1.11 in Gaza and 0.059 in Ukraine. Thus, the rate of attacks on healthcare facilities and personnel in Gaza is 19 times higher than in the next worst conflict of the world. Furthermore, a Ukrainian who flees the battlegrounds of the war will find a functional healthcare system and relative safety elsewhere in Ukraine (many of us have worked in Ukraine, thus we must stress: relative safety), while “there is no safe place in Gaza”. There were 3,412 acute care hospital beds in Gaza at the beginning of the war. This is 1.5 beds per 1,000 people, compared to 7.3 beds per 1,000 people in Ukraine. After the widespread destruction of hospitals there are now approximately 1,400 acute care hospital beds in Gaza, 0.6 beds per 1,000 people (fewer than in Yemen or Sudan), more than 90,000 of whom have been injured by military weaponry in the past ten months. Treating just these injured patients would fully utilize all of Gaza’s current healthcare resources for decades.
Medical ethicist Dr. Arianne Shahvisi asked in the BMJ Journal of Medical Ethics: “What happens when the walls of the hospital are blown away? When neonatal incubators lose power, and premature babies must be kept warm on sheets of aluminum foil? What should medical ethicists do when extreme scarcity [of healthcare resources] arises because the entire health infrastructure of a place is being deliberately destroyed?”
Evidence of Widespread Environmental and Infrastructural Devastation
In January, UN Under-Secretary General for Humanitarian Affairs Martin Griffiths stated that “Gaza has simply become uninhabitable.” The present and future harm to Palestinians in Gaza from the widespread environmental contamination caused by the unprecedented destruction of buildings and infrastructure in Gaza is incalculable.
Those of us who were able to move around the Gaza Strip universally agreed that the level of devastation is simply beyond description. This massive destruction would have been impossible without the repeated provision of purely offensive American weaponry to Israel, particularly the emergency provision of thousands of MK84 and MK82 munitions that were dropped on civilian homes and civilian infrastructure from US-supplied aircraft. According to the United Nations Environment Programme this destruction has already created an estimated 39 million tons of debris contaminated with unexploded ordinance, environmental pollutants, and human remains. The same report notes that the extent of destruction is so vast that it is “unprecedented... For each square metre in the Gaza Strip, there is now over 107 kg of debris...” According to the United Nations Special Rapporteur on adequate housing, Balakrishnan Rajagopal: “All that makes housing ‘adequate’ – access to services, jobs, culture, schools, religious places, universities, hospitals – have all been levelled.” He went on to say that “the scale and intensity of destruction in Gaza is ‘far worse’ than in Aleppo, Mariupol or even Dresden and Rotterdam during the Second World War.”
After reviewing the available information a group of 40 international public health scientists concluded that “we must call attention to the devastating consequences for public health and the lives of future generations resulting from Israeli military action and its impact on the Gazan environment.” They noted extensive damage or destruction to half of Gaza’s buildings, 60% of its housing stock, the razing of 45% of Gaza’s farmland, destruction of 70% of Gaza’s fishing boats, the killing or premature slaughter of 60-70% of Gaza’s meat and dairy livestock, and “an untold amount of damage to animal habitats and ecosystems.” Today “much solar equipment lies in ruin amidst the thousands of buildings destroyed, alongside pulverized building materials containing hazardous materials such as asbestos and other debris.”
As of April 2, the World Bank estimated the physical damage to Gaza “at around $18.5 billion”, which they note “is equivalent to 97% of the combined GDP of the West Bank and Gaza in 2022.” The UN Commission on Trade and Development estimated Gaza’s 2022 GDP at $2.72 billion. In other words, since October 7 Israel has caused physical damage to Gaza equivalent to 6.8 times Gaza’s annual GDP.
