Palestinians recite a prayer over bodies of persons killed in Israeli bombing in Deir el-Balah in the central Gaza Strip before their burial on March 14, 2024, amid the ongoing war between Israel and the Hamas movement. Credit - AFP-Getty Images
The first shock was the number of people killed in Israel—1,200 in a day, Oct. 7. But in the months since, the world has been taken aback by the number of deaths reported out of Gaza: 30,000 through the end of February. Because the death count is compiled by the local Ministry of Health (MOH), an agency controlled by Hamas, which governs Gaza, the tally has been subject to skepticism. Israel’s U.N. ambassador and online pundits have purported that the numbers are exaggerated or, as a recent article in Tablet alleged, simply faked.
Actually, the numbers are likely conservative. The science is extremely clear.
In December, the medical journal The Lancet, published two critiques of the death surveillance process done by extremely experienced scholars at Johns Hopkins and The London School of Hygiene and Tropical Medicine. Both concluded that the Gazan numbers were plausible and credible, albeit by somewhat different techniques and logic.
The Hopkins’ analysis looked at internal aspects of the data like comparing hospital trend reports to the overall numbers, but also compared the death rates among U.N. employees with the overall MOH reports in terms of trends and mechanisms of death. There are a huge number of U.N. employees in Gaza, and very close correlations between the rates of death of U.N. employees and the overall population, and regarding the fraction dying under bombs in their homes.
The London School’s analysis looked at some of the same issues, found near perfect correlation between Government bombing reports and satellite imagery, but focused on 7,000 deaths reported through health facilities and morgues during last October. In Gaza, there is a resident ID system which involves a number assigned to young children, and the assigned numbers have risen sequentially over more than half a century with a couple of exceptions. At two different times 20 years apart, there have been “catch-up” campaigns where people of any age who had been missed or had migrated to Gaza could get an ID number. The data analyzed by the London group came directly from many health facilities and morgues, and constituted most of the summary numbers later released by the MOH. In the data, when people’s ID numbers were plotted against the decedent’s age, there were two broad bands of age associated exactly with the ID numbers that had been given out in those catch-up campaigns. Given that this data was flowing from many different medical and morgue facilities, the authors concluded that it is very unlikely that there could be meaningful data fabrication.
Read More: What U.S. Doctors Saw in Gaza
But, the evidence supporting the Gaza MOH mortality number credibility goes beyond these two assessments.
In 2021, an assessment of the MOH mortality surveillance system found that the system under-reported by 13%. In past crises, Doctors Without Borders (MSF) and UN reports have aligned closely with those of the MOH in spite of Israeli dismissals. Most countries in the world record far fewer than 87% of their deaths, but Gaza has many characteristics that make surveillance work well. In spite of relatively high rates of poverty, this is a highly educated population that is engaged with the health system. For example, a USAID funded assessment found in 2014 that 99% of births were attended by a trained health professional compared to about 80% globally. Gaza is geographically small and people have a relatively short distance to reach health facilities. Thus, nothing about Gaza’s MOH high level of function should be triggering this skepticism.
Do the Gaza MOH numbers combine combatants and civilians? Yes, but this does not imply manipulation. Making the distinction is sometimes not called for and is functionally hard for the health system to do. There is something imperfect in every government measure, but that does not mean they should be ignored.
I speak from experience. In 1992, by a fellowship lottery process and a lot of luck, I ended up working in the Refugee Branch at the Centers for Disease Control and Prevention, CDC. The CDC was an amazing place, with so many inspiring people, and an ever-present sense of community and its history. In my four years at CDC, many times I heard about how CDC was the first institution to epidemiologically measure the death toll in real time during a war. Right at the close of the Biafra War in 1970, a young epidemiologist borrowed a technique from wildlife biology called capture-recapture, and estimated that half of the population within the enclave of Biafra had died. What I only recently discovered, is that this death toll was never reported in a public venue. It seems that Richard Nixon ran for office aggressively criticizing President Johnson for allowing the Biafran Famine to occur. Two years into his own Presidency, a revelation that probably between one and two million people had died, mostly on Nixon’s watch, would have been politically embarrassing.
It seems death tolls in wars have always been political. Be it the sinking of the Maine and the death of over 200 sailors in 1898, likely from a non-intentional fire, being used as an excuse to start the Spanish-American war, or General Wesley Clark in 1999 citing exaggerated numbers of dead in mass graves in Kosovo to justify that war. What is comforting, is that usually over time, reality and science have a way of gaining acceptance, sometimes even while the conflict is underway, such as Syria.
In fact, there may have never been a major conflict where real-time surveillance data about deaths was more complete than is unfolding in Gaza today.
There are certain building blocks of society that require agreement for us to work well collectively. Society is weaker and discourse less productive if we cannot agree on at least a few basic things. In the case of Gaza, acknowledging that there was an appalling and extremely deadly attack on October 7th, and that over 30,000 Gazans have died since, mostly women and children, seems like the most basic of cornerstones of reality on which to move toward constructive discussion and eventual resolution.
