Last week, while the UK focused on the end of the disastrous Conservative government, France celebrated its narrow escape from far-right rule and Europe in general obsessed over a football tournament, a brief but devastating article appeared in The Lancet’s correspondence section.
Entitled, “Counting the dead in Gaza: difficult but essential1”, its authors estimate the indirect mortality of the latest war on Gaza, now in its 9th month, at 186,000 civilian deaths. As horrific as that is to contemplate, the true figures could even be considerably higher.
What is “indirect mortality”?
Direct mortality figures reflect the impact of the violent activities of conflict2.
Indirect mortality is that which occurs as a consequence of the conflict and can be from reproductive, communicable or non-communicable causes2. For example, people cannot access life-saving treatment for treatable acute or chronic conditions or when injured in accidents.
In Gaza, this could conceivably include:
· ante-natal or post-partum haemorrhage leading to excessive maternal and neonatal mortality,
· infants dying from vaccine-preventable conditions such as measles, diphtheria and tetanus, due to disruption of the routine immunisation programme,
· cancer patients facing delayed diagnosis and no access to treatment,
· no access to kidney dialysis or treatment for diabetes, hypertension, heart attacks and stroke,
· mass displacement and over-crowding with no access to clean water or adequate sanitation, leading to infectious disease outbreaks, potentially including cholera, and
· lack of access to appropriate antibiotic treatment for treatable common childhood conditions, such as pneumonia, meningitis and sepsis.
A 2020 study3 investigating civilian mortality in 1,118 separate armed conflicts, across 193 countries, between 1990 and 2017, found that war led to an additional 29.4 million deaths over that period. This was shown across all age groups and both genders, but the worst impacted were children aged 0-5 years3. The breakdown of this excess mortality figure was:
· communicable, maternal, neonatal and nutritional conditions – 21 million
· communicable diseases – 6 million
· injuries (i.e. direct mortality) – 2.4 million3
Thus for every civilian killed directly, there are 11 indirect deaths. Indirect mortality can continue long after the violence ends, and this is likely to be the case in Gaza where no element of civilian infrastructure remains unscathed – there has been deliberate and wholesale targeting of the health and humanitarian sectors, disruption of water and sanitation systems and food and aid distribution systems and destruction of over 70, 000 housing units, with 1.9 million of Gaza’s 2.1 million population currently displaced4.
How accurate are the Gaza casualty figures?
Conflict casualty figures may be over- or under-reported for political purposes. During the ongoing war on Gaza, politicians and media agencies have often been guarded in reporting the mortality data from the Gaza Ministry of Health (MoH)5. This scepticism risks undermining the case for a ceasefire and desperately needed humanitarian assistance5. Due to the ongoing security concerns, it is very difficult or often impossible for independent verification of these figures. Historically, the Gaza MoH mortality reporting has proved accurate, with independent United Nations analyses finding discrepancy rates of 1.5-3% at most.
Another letter published in The Lancet last year compared the Gazan MoH figures with reported staff fatalities from UNWRA. The UNWRA mortality rates were substantially higher than those reported by the MoH – if the Gazan authorities were indeed seeking to inflate mortality data, the reverse could be expected to be true.
Graph from The Lancet, 20235
As the war has raged on, with direct attacks on MoH facilities and personnel and amidst the chaos of war and destruction, their capacity to report deaths has dwindled. In their OCHA reports, the UN cite only fatalities that, “the MoH in Gaza has recently fully identified out of the higher number of casualties they report6”. Thus numbers such as 10,000 reported missing or under the rubble, and 17, 000 unaccompanied children6, have not been updated in months.
Given this inability to record even direct mortality, the restricted access to food, water, electricity, medicines and humanitarian aid, and the massive destruction of the civilian infrastructure, and the health sector in particular, the concern must be that the scale of the humanitarian catastrophe unfolding in Gaza is thus far underestimated. Last week’s letter to The Lancet explained that indirect mortality may be estimated by multiplying direct mortality by anything from 3 to 15. The authors chose a factor of 4, which is conservative in the extreme, given the conditions cited in this blog.
What should Labour do next?
We welcome the appointment of Richard Hermer KC as the Attorney-General. This must ensure a much stronger stance from the UK towards the Israeli government, in order to bring about an immediate and permanent ceasefire; starting with an immediate embargo on arms exports to Israel and safe evacuations for casualties and their families (and indeed anyone at risk, with the establishment of something akin to the visa scheme offered for those fleeing the war in Ukraine).
In addition, we need to see complete acceptance of the International Court of Justice (ICJ) ruling, re-funding of UNWRA and unfettered access to food, water, power, medicines and humanitarian aid – aimed not just on sustenance but complete rebuilding of Gaza.
References
1. Khatib R, McKee M, Yusuf S. “Counting the dead in Gaza: difficult but essential.” The Lancet. Published online on July 5th 2024, DOI https://doi.org/10.1016/ S0140-6736(24)01169-3 2.
2. “Direct and indirect conflict deaths.” Every casualty counts. Last accessed 11th July 2024.
3. “Estimating indirect mortality impacts of armed conflict in civilian populations: panel regression analyses of 193 countries, 1990-2017.” Jawad et al. BMC Medicine. 18:266 (2020) https://doi.org/10.1186/s12916-020-01708-5 4.
4. OCHA OPT Updates page, https://www.ochaopt.org/ last accessed 11th July 2020
5. “No evidence of inflated mortality reporting from the Gaza Ministry of Health.” Hunyh BQ, Chin ET, Spiegel PB. The Lancet. Published Online December 6, 2023 https://doi.org/10.1016/ S0140-6736(23)02713-7
6. “Reported Impact Snapshot | Gaza Strip (10 July 2024)” OCHA https://www.ochaopt.org/content/reported-impact-snapshot-gaza-strip-10-july-2024 last accessed 11th July 2024.