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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@[Link]) 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

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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

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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.”

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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

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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 Health reported 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

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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

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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
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

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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

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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.

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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.

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