A Complete Impasse—Gaza: The Human Toll

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This transcript is from a CSIS event hosted on July 10, 2024. Watch the full video here.

J. Stephen Morrison: Hello, and welcome to this 14th episode of Gaza: The Human Toll. It’s a broadcast series put together by the Center for Strategic and International Studies, CSIS, here in Washington, D.C., the Bipartisan Alliance for Global Health Security at CSIS, in partnership with the CSIS Humanitarian Agenda and the CSIS Middle East Program.

I want to offer special thanks to our marvelous production team at CSIS here – Eric Ruditskiy and Qi Yu, and to my colleagues Sophia Hirshfield and Anna Russin – who helped pull this all together.

Today we’re going to be joined by Dr. Rik Peeperkorn, who has come on this show a couple of other times. He is the WHO representative in occupied Palestinian Territory, and that of course includes quite a deep immersion in Gaza. He’ll be telling us today about a recent trip yesterday with Hanan Balkhy – Dr. Hanan Balkhy, the regional director in Cairo for the EMRO office, the World Health Organization regional office there.

We’ll also hear from Cameron Hume, who is the executive director of the Maritime Humanitarian Aid Foundation, which is the funding arm of the Blue Beach Plan launched by the firm, Fogbow, which is delivering relief into Gaza through a maritime corridor. We’ll hear more about that. Cameron is a retired career diplomat and close friend who served as our ambassador in Indonesia, Algeria, South Africa, and Khartoum in Sudan.

We’re also joined by my colleague Michelle Strucke, who’s the director of the CSIS Humanitarian Agenda and the Human Rights Initiative and is the Khosravi chair for principled internationalism.

We’ve all been watching these recent developments, the intensification of the war, the forced evacuations of 250,000 in and around Khan Younis, 70(,000)-80,000 in and around Gaza City, the repeated airstrikes and ground offensives that have – that have given us a series of strikes on schools and shelters in and around Khan Younis and Gaza City. We’ve also seen some major data analytic work come forward – the nutritional vulnerability analysis which documented the malnutrition status, the lack of access to water, and health infrastructure, and what the what it means to have had a million displaced since the beginning of the most recent southern offensive in the first week of May.

We also had the IPC report that was issued around the same time, the Integrated Food Security Phase Classification June 25th, which showed that just under 500,000 people on the brink of starvation, with a projection that by the end of September, 96 percent of the population will be in either emergency, crisis, or catastrophic status with respect to malnutrition. We’ve also seen quite a bit of activity by Ambassador Sigrid Kaag, who is the special envoy on Gaza for both humanitarian and reconstruction purposes. She reports to the U.N. – to the U.N. Secretary-General. And her mandate emerges from the Security Council Measure 2730.

She has begun to put in place oversight mechanism and reported July 2nd to the Security Council, making some fairly dramatic statements around the lack of political will and the need to begin thinking about restoration of civilian infrastructure, sanitation, water, health infrastructure, road systems, and the like, if there’s going to be any reversal of the severe decline in the humanitarian and health status of the population.

We have also had the most recent piece put out by The Lancet, “Counting the dead in Gaza: difficult but essential,” which had a few striking points. One is that fully 30 percent of the now 38,000 deaths in Gaza were unidentified, and there’s an estimated 10,000 that have died in the rubble that have not been – not been unearthed. Indirect death tolls could be as high as 186,000, which would bring us to almost 8 percent of the total population. These are somewhat staggering numbers.

So let me – let me now turn the floor over to Rik Peeperkorn to kick things off. And then we’ll hear from Cameron. And then we’ll have a conversation that follows for the balance of the hour. Rik, thank you so much for joining us today, coming in from Jerusalem. We really appreciate you making time in your – in your crazy schedule to be with us. Thank you.

Richard Peeperkorn: Thank you very much, Stephen, and colleagues. And greetings from Jerusalem.

Yeah, let me maybe start with some of the impressions of my – actually, my one-day visit yesterday to Gaza. And I want to raise a few other issues before I come with a few key asks. A key ask would be we, I think, have always included in this program. So I have my – the WHO regional director for EMRO, Dr. Hanan Balkhy, with us for the last, actually, 11 days. And an incredibly insightful visit, I think, for all parties. We went in depth, actually, on everything related to West Bank. If you have any question on that, I can also answer on West Bank, East Jerusalem. But, of course, the Gaza crisis tops everything. And we had difficulties getting a visit organized, but we managed yesterday.

And just a quick – because having been myself much longer time in Gaza in late November and then a couple of weeks in December, in February, number of weeks, and in April, and I wanted to go again. The last couple we couldn’t manage because of their schedule. But will be going again to join my team. But there were a few things. We had – of course, we had a meeting with head of agencies in Gaza, from all humanitarian agencies and NGOs. And a few things came out, which we hear all the time. And I think you referred to it already, Stephen, at least to a few here.

The first and major concern is public order and safety. And that’s currently almost nonexistent because of the lack of the so-called blue police, which I think from Israel is seen as well. They don’t want to deal with that, so they are not operational. And that has created a vacuum. It’s always most difficult with this – it’s now – and you see it in front of you – it has created a real complex situation; a situation which is, of course, first and foremost, affecting the Gazans most, but it’s also affecting all humanitarian operations. So that has to be addressed. Public order and safety needs to be restored to ensure that Gazans are free to move, but specifically that humanitarians – U.N., NGOs, anyone else – can actually do the work.

The second point which is consistently mentioned, I think, over the last nine months now, is the fact that fuel – fuel supply – is still currently not enough. And I think it’s – I think Scott Anderson – and I’m sure you mentioned it again yesterday – there’s a need roughly of 400,000 liters a day. And fuel is straggling in every time. It’s never 400,000. Only the health sector needs 80,000 liters a day; wash, something like 70,000; et cetera, et cetera. Now, the – what they got in, for example, the last time, was 90,000 to cover all the sectors – hospitals, wash, food security, bakeries, et cetera. And even, by the way, for internet and internet connections, there is need to get fuel in.

That’s affecting also – there was a number of, I would say, smaller NGOs. They also mentioned that not only the security, but also the lack of fuel showed they couldn’t do what they should do – working with the communities, et cetera, bringing in the communities, going from one place to another, because of the lack of fuel. Very simple. And we are discussing this for the last nine months.

Medical supplies. We still have a big problem with medical supplies, as was mentioned by all the U.N. agencies – of course my own team, but also some of the NGOs who actually are managing their field hospitals or EMTs, emergency medical teams, specific medical supplies. And what’s the problem here? Since the Rafah crossing closed two months ago, so that is – for WHO it’s overall to these partners providing 80 percent of their medical supplies. And a lot of those supplies do not get in anymore through the Rafah crossing because it closed. So now they have to go to – (inaudible) – Kerem Shalom. Much less is coming in. And also, we cannot get it in in containers. So we’re missing the temperature-sensitive essential medicines and vaccines. It’s a big issue. And that’s mainly for the south. We tried to get something in through the north, but we cannot bring that to the south. So it’s an – it’s an issue, and then there’s also specific needs in some – in some areas.

So Rafah crossing remains closed. And collecting aid from Kerem Shalom and – (inaudible) – as well – (inaudible) – it’s challenging, very challenging, because of the insecurity. A lot of supplies stack up. It’s difficult – it remains difficult to do a proper job getting there, bringing it out, and storing it at other – in other places.

Last point on this overall is the garbage and sewer is filling the streets, open sewers even in Deir al-Balah and other places, et cetera. It’s, of course, a petri dish for many diseases. And maybe if you have a question later on the diseases, I’ll get back to that. But I want to keep first to things general.

A key point which I want to raise is, of course, hospital functionality. And I want to come back to some of the evacuation orders. So, currently, as we describe it, only 30 of the 36 hospital are partly functional for a population of 2.2 million people. There are actually only – because it’s more important, maybe, to talk about that and that capacity.

Before the war, there were 3,500 hospital beds in Gaza. Currently, there’s a thousand beds or less. And from these thousand beds, almost 370, almost close to 400, are actually now served by field hospitals. So from the 3,500 beds, yeah, we – there is actually at the moment only 6(00) to 700 beds left. From the 3,500 hospital beds, there’s between 6(00) and 700 hospital beds left. That is a completely unacceptable situation. With field hospital we are roughly at a thousand at hospitals.

So Gaza City – and I think you mentioned Khan Younis; I want to get back to that. But Gaza City yesterday evening got also evacuation orders, increased fighting in these areas over the last couple of days close to Gaza City in the north. So Al-Ahli Hospital and Patient-Friendly Hospital are out of services. And what happened, I think – and the same happens to other hospitals – so patients, even when we are told – WHO has also been informed, oh, but the hospitals, they are OK, you don’t have to evacuate hospitals; we cannot tell them anymore because the patients and the health workers, they are deeply – well, they are afraid, and rightly so, because based on their experience in the past, when hostilities come close patients cannot come and go. Ambulances cannot come and go. Health workers cannot leave or cannot come. So a hospital becomes an island. And WHO partners, we cannot provide medical supplies and fuel, which is essential for those hospitals. So this hospital becomes an island, and we have seen this. I mean, like, WHO was the one – myself in those missions, we were part of the – I was part of the mission getting the last hundred patients out in the midst of hostilities in horrible conditions and health workers.

So this is what happened. People – so people don’t take that risk anymore and evacuate before. So Al-Ahli, Patient-Friendly, out. Al-Helal Hospital, that’s actually within blocks. It’s all in the north, all these evacuation orders, but continues to be partly functional, as well as Al Sahaba and, surprisingly, Al-Shifa on the – on the complete destruction and damage. Again, it’s partly functional, and they remain functional so far.

So PRCS reports that most of those medical points and an emergency clinic in Gaza governorates are out of service as well.

You referred to Khan Younis and the evacuation order there, Stephen. And that had, of course, a huge impact on the European Gaza Hospital, which was one of the key referral hospital together with Al-Aqsa and at the moment, again, Nasser Medical Complex. European Gaza Hospital was actually key for a lot of things and had close to 750 beds when it was operational. So within one day, one night, with the evacuation orders most patients either self-evacuated or were assisted by partners – WHO partners – to be evacuated to Nasser Medical Complex and to other field – some of the field hospitals, the most serious patients.

We also helped the hospital to get – well, get important medical equipment out of the hospital to other places, et cetera. And this is what happens. This is how quickly it becomes in – ICRC, unfortunately, also left, had to leave, et cetera. But that hospital is currently nonfunctional.

And from the field hospital – I will get back to that.

So maybe on yesterday as well. So we also visited, and I want to make a complete difference – we visited IMC field hospital as well in Deir al-Balah, which is – and I want to say also when we were at IMC – International Medical Corps – it’s a good story actually for what happened in Gaza. They started their first field hospital in Khan Younis. They had to move, and I think I told you about that, Stephen. I visited a hospital, et cetera, and they had to move because of hostilities. They went to Rafah-Mawasi. Actually, they were next to the WHO Guest House. And recently they had to move, just as we had to move from Rafah-Mawasi to Deir al-Balah and now they are established in Deir al-Balah. The bed capacity is, like, 150 beds, 75 percent covered. It handles between 700 and a thousand cases in the OPD per day. Number of surgery, 10-15. Number of delivery, 10 per day. We met a 7-year-old girl who was actually recovering from malnutrition which we actually, I think, transported from the WHO stabilization center to the hospital, was moved from Kamal Adwan, et cetera. And I think we are really close partners with – not only IMC, with all, there’s UK-Med, ICRC. Everyone who operates in a field hospital we try to assist as much as possible with medical supplies, fuel, and medical equipment.

So coming to what I would say are the – our key asks at the moment. And maybe we come back to that later, but key asks. The first one is, of course, which we have raised for the last nine months, is protection. And protection for health and for health workers, for hospitals, for health facilities. And we have consistently failed in that. We have lost – down from 3,500 beds to 600 beds, plus 400 other beds from field hospitals. That’s where we are now. For 2,000 hospital beds, for 2 million people, in a war.

Now, the other key ask is on medevac. OK, on medevac. So medevac is not happening anymore, except for small group of cases – a very small group. Is not happening anymore since the Rafah crossing closed. So WHO is very ready. And we are working now with all partners to get started again in an organized way. So I want to make the point that before the Rafah crossing closed, 4,900 patients were medevacked, mainly into – and into Egypt, where the majority were treated in Egypt, and 2(,000), almost 3,000. And the rest is treated mainly in the region. And then a few others.

Now, we – a number of countries in the region have reached out. They are willing to accept more patients – willing and ready. Egypt also had made that point. Countries in the region and also some European member state reach out. So we are trying to work with all partners, and have an SOP ready. We have a plan for that. We estimate that at least 10,000 patients need to be medevaced outside Gaza. Half of them is war and trauma related, and needing probably multiple – think about reconstructive surgery, spinal injuries, amputees, et cetera. The other half is, like, chronic diseases, a lot of oncology, but also cardiovascular, mental health, et cetera, for specialized care.

We ask for corridors. We need safe corridors to get those patients out. And we ask for all corridors possible. The first corridor we’ve asked for, to all parties – of course, the corridor where patients were referred to before this crisis is the corridor from Gaza to East Jerusalem and the West Bank. We also visited East Jerusalem hospitals. They are ready to receive patients from Gaza currently, including in the west. That’s the first corridor we ask. We ask for a corridor to Egypt, for Rafah crossing opens. If the Rafah crossing is not open yet, then through Kerem Shalom, then Salah, into Egypt. And the other crossing we are asking for is to Jordan.

And I think we need all support for that, to make sure that medevac becomes organized, safe, and sustains. And this is going to be a process not just over one month. We are realistic about – we’re not going to help medevac for 10,000 patients over the next three months. This is going to take a year or longer. And we also should realize, this should continue even after a ceasefire, et cetera. Because before the ceasefire, approximately 50 to 100 patients were referred out of Gaza to East Jerusalem and the West Bank every day. So that’s like 500 per week to a thousand to 2,000 per month.

Now, the – so this – and my last, maybe, points is I want to request we also discuss – it was raised also in Gaza – a concern we have on detains health workers, and we have raised this before. It should be on the agenda. And their families, their organizations are – rightly so – deeply, deeply troubled and concerned about this.

I think, Stephen, I want to stop here. I’m sure there will be some questions later. Over to you.

Dr. Morrison: Thank you, Rik. Thank you very much. We did have Scott Anderson, head of UNRWA Gaza, on our most recent show, and we actually also had the staff from the IMC field hospital on, and we visited that field hospital and made a short video from it – the original one in Khan Younis.

The question of protection, evacuation, and detainees that you outlined, what’s the nature of your dialogue right now with the Israeli Defense Force and with Israeli officials on these matters? Can you tell us anything about that? And how many detainees do you have?

And I’ve seen, you know, the U.N. secretary-general’s press spokesperson last week talking about the need for armored vehicles, for better communications, and for higher commitments from the IDF for protection purposes, so that’s coming straight out of the secretary-general’s office, those messages. What can you say about that?

Dr. Peeperkorn: Yeah. I completely – I didn’t want to mention that I called it the general – the general request, I mean, like, with the calls. I mean, look, what I raised from the start, of course, the key: the public order, the safety, the fuel. I mean, linked to that is, of course, the comms equipment, the AVs, and everything related to that.

Everything actually related, how do we make sure that humanitarian organizations – the U.N. and its partners – can do its work safely, and as effective and efficiently as possible? And there are still massive gaps in all these areas, and I think it’s – yeah, so I completely agree with – I know that you just spoke with Scott Anderson. And secretary-general, I know that Sigrid Kaag and others raised some of those issues as well.

On our discussion, we constantly have discussions. And I say that when we have discussions, including on this evacuation – and so we see these evacuation orders, and we get approaches by a lot of the hospital those who need to be evacuated – we are much clearer now. We say that this is – this is not my position, by the way, first. I’m not a patient there. I’m not a health worker there. But health workers and patients and EMTs, they have learned their lessons – they have learned their lessons from Nasser Medical Complex, for Shifa, for hospitals al-Najjar, in hospital – the Emirati hospital, in al-Najjar, in the RCH hospital, in the – in Rafah. They’ve learned their lessons.

And so we are counseling them – of course, the next question we have – even if the crossing stays closed, can you please make sure that the hospital doesn’t get damaged, et cetera, so that we can restart the operation as quickly as possible? And you see how difficult that was simply in Shifa but also in Nasser. I mean, it’s amazing to see that kind of resilience from the health workers in Gaza. Nasser Medical Complex, I mean, like, it got close to my heart because WHO supported Nasser for over tens of years, for example, with a limb reconstruction unit, famous limb production, help to prevent amputation, vascular surgery, et cetera, top optima forma. And it did wonders over the years.

So that was the goal. As I said, came under siege, what was it, in February, and became so badly under siege – under siege, damaged, et cetera. And a group of health workers and staff and patients stayed. Well, terrible consequences. So they begged us for assistance to get them out. And we negotiated and negotiate; had a lot of delays before we could get them out under horrific conditions, I mean, for patients, and unnecessary increased morbidity and mortality, but also for the staff. The same happened in Shifa, where we also assisted and helped, and the same issue here. We are in constant dialogue, et cetera.

And currently, of – it’s a little sad to say, because every time when I see this I also have something, oh, that hospital – health workers should stay in the hospital and staff should stay in the hospital. Suppose I was now their surgeon, I mean, or I was a health worker, or I was a patient. Would I stay? No, probably not. Lesson learned. You know?

Dr. Morrison: Yes.

Dr. Peeperkorn: And I think then the only discussion is how do we make sure that that get protected.

And the second point is: How do we expand the bed capacity? And so we are helping field hospitals with expansion of capacity and bed capacity. But we are also helping, for example, Kamal Adwan and the hospitals in the – in the north, which all not – please don’t forget, a couple of weeks ago Kamal Adwan and Al-Amal were nonfunctional because of the siege around. They are now again partly functional. And this is the same what I said from Nasser Medical Complex. With the resilience from the health workers and support from WHO and partners, these hospitals are now again partly functional.

So it is working. We have to make sure we support them, and we expand that capacity and the cooperation to make sure that the right supplies come in, et cetera. There are health workers, and there are still many fantastic and well-qualified Gazan health workers which need our support. Over to you.

Dr. Morrison: Thank you.

Cameron, tell us a bit about your maritime initiative. What’s the status of that? What have you been able to accomplish? Tell us a bit about that.

Cameron Hume: OK. Thank you very much, Steve.

First of all, I’d like to say that I think all of us owe a real debt of gratitude to the people who are working inside Gaza, whether it’s the medical fields or in other fields, to try and deliver aid from the entry points to the actual people. And they’re the – they’re the individuals who are taking the risks and carrying this burden.

The effort to put in a maritime corridor, I think, gained most notoriety when President Biden announced his initiative for JLOTS, which I think has to be welcomed as a – as an indication that the president understands the United States has both a moral and political responsibility to see that necessary humanitarian supplies are made available for use within Gaza. Now, I think it’s fair to say that the JLOTS pier was not particularly fit for operation in that environment. We have cooperated with the JLOTS operation. And in fact, about 20 percent of the material – mostly food – which has come in across JLOTS was contributed by the organization I work with.

The key point, which Rik emphasized, is we have to not only be able to get food and other supplies to the crossings; we have to get them through the crossings. But the really hard part is what happens once it gets through the crossing. How do you get it to a safe place so that there is a distribution center that can then move the humanitarian supplies, whether it’s food or medical equipment, into the hands of these humanitarian workers and into the hands of the communities who need them for survival?

And one of the things that I found most encouraging about our own operation is, of the 1,200 pallets that we were able to deliver to the beach in Gaza now 10 days or two weeks ago, all of those pallets have left the beach and they’ve gone – they’ve been taken by the World Food Programme; put into a central distribution warehouse; and 200 of those pallets have, in fact, gotten to the community workers who are working in community kitchens; and some of the food is also put into the commercial network as the best and most efficient way to distribute it to the Palestinian people. Tough work, but essential.

And that’s that – why has the maritime route been more successful at getting food into Gaza than coming across the land crossings? It’s mostly because of the chaotic situation that Rik described he confronts in Gaza, that if you land the supplies in an isolated area on the beach you have somewhat better chance of being able to get past the – I don’t know that there’s a diplomatic word for it, but the gangs and the others who are trying to steal or muscle to get resources from the humanitarian operations. And our experience, I’m very glad to say, has been we’ve been able to avoid that. I realize how difficult it is. I don’t know that there’s a way for the Security Council and the outside community to provide security in Gaza. It’s a warzone. And it’s a warzone with irregular forces. And by definition, that leads to chaos. And the challenge we all have right now is, on the one hand, trying to get a ceasefire that’s good, but also how do you operate in conditions of chaos?

One of our efforts that we’re ready to make is to help with the rebuilding of the Gaza Industrial Estate, a facility that’s not far – it’s in the northern part of Gaza. And we believe that helping to rehabilitate that is in line with Sigrid Kaag’s request to the Security Council. She explained you can’t – and again, what Rik said was a very vivid description of the problems. Unless you rebuild parts of the civilian infrastructure, you cannot do the necessary humanitarian work. Maybe you can do it for a weekend, but you can’t do it longer term.

And so, even as we look at bringing in food, if we look at bringing in medical supplies, the international community has to also be ready to engage promptly on rehabilitating parts of the civilian infrastructure that allow everything else to happen. And the Maritime Humanitarian Aid Foundation already has plans and partners to go ahead and do that in the Gaza Industrial Estate.

Dr. Morrison: Cameron, the JLOTS, the Department of Defense pier, the general estimation is that it cannot operate for more than a few weeks, right? As we get into August and September, the seas become too rough. It’s had a tough time in any case since the very beginning, when it was stood up. What happens when that goes away?

Mr. Hume: That’s a great question. We are ready to use the plan that we had before JLOTS was announced. And that plan, we use oceangoing barges, which can bring in over 100 trucks per barge. They can operate in nine-foot seas. The JLOTS pier can operate in only three-foot seas. And it would require us to do some dredging at the beach point and put in some protective barriers. It would take three to four weeks in order to be able to do that.

And if we – if our partners in the humanitarian community indicate that they will use these facilities, we’re ready to go ahead and do that. But it’s not exactly a chicken-and-egg problem, because we know it can be done. It’s a question of trying to build up the confidence of the humanitarian community that a significant proportion, about 20 percent of the total estimated amount of aid needed by Gaza, can come in by sea.

I would point out, as a comparison, you’re now getting in 15 or 20 percent of the amount of aid. So it would be half of what’s coming in right now.

Dr. Morrison: Rik, before we turn to Michelle, did you want to offer any reactions to what we just heard from Cameron?

Dr. Peeperkorn: Yeah. And I want to add also one general point, if I may. So, you know, I think we have to look at this a little differently. Before the war, 500 trucks a day entered Gaza. Yeah, 500 trucks per day. All through road crossing. Do we – I think this has been raised by the U.N., the humanitarian organizations, consistently, that the road crossings are most efficient and effective. And, of course, how that comes in is a different story. I mean, like that –so if – and we see this now. And this, I think, is a positive change, so let me say something positive, that our – (inaudible) – port can be used. And then from our – (inaudible) – ports you bring it into either north Gaza or south Gaza. Other routes can be used. Local procurements in Jerusalem, West Bank, and Israel to make sure – that’s important for the medical supplies, for example, to get it in.

So I want to make a point on the – but let’s not mix the two things. Because it’s – so the U.N. has always been on that, and myself, about every option is good, and to act. But let’s really focus what are the most cost-effective options. And those are road entries into Gaza, which always work.

I also want to say something about security. If you would have more beach landings, you will have security issues on the beach. If there is a lack of security and a lack of public order, that’s a completely different thing. That has to be tackled. And that should be – there should be ways within Gaza, outside Gaza, international partners, whatever you think about it – also, when you think in future, if you would get some ceasefire arrangements, et cetera – then of course, the public order and safety and security is a top priority; that people can move, people feel safe.

There’s a lot of other stories, as well. I mean, I didn’t even discuss that – the baseline, et cetera, all related to that. I mean, but the public order and safety is at least – it will be – is key and will be key for any operations. So I don’t think that we should not say, oh, we can do this more and we’ll be safer when there’s beach landings over there. No, we should look at what is the most cost-effective way to get boots into Gaza. And the most cost-effective way – has been there before the crisis, during the crisis, will be after the crisis – will be land crossings and over the road.

Now, I want to make a point – and maybe another point I want to make is – and you know, having been there and so on, specifically when I talk to Gazans themselves and to my Gazan colleagues and the team, but also the humanitarians who constantly work there ourselves, who go there and work there on matters, it is very easy when you look at it – and also, yesterday I discussed with my regional director, too – that you do become very quickly very desperate and almost depressed, and say something like, well, what are we doing here; this has no future. The destruction is so immense. The total – and not just – everywhere. The infrastructure – basic infrastructure – schools, health, food, you name it, industry, whatever is there.

And people are traumatized. I mean, think about mental health consequences this has for children, for the youth, et cetera, and also for animals and old people. So it’s very easy to slip in that mode, and I think we all have that. Definitely, Gazans have that. Definitely, they slip into this, what am I doing there/here. And again, however I’m in, we come back; we dare to stay and deliver.

And I want to say something about resilience, which we see in every area. And other colleagues, other U.N. agencies will be able to say something about wash and wash restoration, or water supply. We can things about health and the enormous resilience we see. And of course, we have to work on the future.

And this is what I didn’t mention, and I should have mentioned at the – as the third key ask, but maybe I feel it is of course peace and a ceasefire, and moving towards that. And with that ceasefire – and we are already making plans. The first plan – and it really helped us from October – we focused on health – on health service delivery. We saw many casualties, the whole trauma pathways, et cetera, the emergency medical teams, the links to them, et cetera, the referral system. Public health intelligence was a second area – early warning system, epidemics, prevention and control. The third one was supplies and health logistics, which underpins almost everything on the – and then, of course, emergency coordination. And in our role as WHO, we coordinate and help all those partners.

We added, now, in our new plan – new operational plan – we added early rehabilitation and reconstruction. And as we focus, of course, in health, so how do we – there will be humanitarian maritime – (inaudible) – for years to come, but how do you transition that to provide emergency response as well as longer-term recovery, including establishing of temporary health facilities that will be needed for rehabilitation of the existing infrastructure, supporting the health workforce. Let’s not forget that most of them, they work as volunteers currently, so think about that. Capacity building initially in teams will be needed, et cetera. I’m not just talking about health.

There’s other part of this, et cetera. U.N.– (inaudible) – thinking already on its policies on education and in food security, et cetera, and it needs to be part of the overall plan. So we need to have this constant – this, locally, what I call the overall picture.

In the meantime, we have to be as operational as possible. In health, WHO and our partners definitely will focus, and we continue to focus on, and we raised a couple of issues, like this needs to be made more efficient. And getting back to all the entries, road entries, are by far the most cost-effective.

Dr. Morrison: Thank you, Rik.

Mr. Hume: I would like to point out that everything that Dr. Peeperkorn has said is true. Road entries are the most efficient, if you get the food through the road entry and distributed. And the percentage of food and other supplies, as the doctor indicated, that comes through the road entries is far from adequate. What we are offering and providing is an additional capacity, which is significant. Twenty percent of the total aid that’s come across the JLOTS pier has been from us. Yes, without a ceasefire everything is difficult. However, the last nine months have taught us that we have to be able to operate in the situation in which there is no ceasefire, and in which there is chaos in Gaza. Otherwise, people will die. So it’s not a question of either/or. It’s a question of both/and. Thank you.

Dr. Morrison: Thank you so much. Michelle.

Michelle Strucke: Thank you so much for having me. And thank you, both of you, for your great interventions.

I will seize upon one thing you said, Cameron, which is war is chaos. I would say that while war can be chaos, this war is chaos. Not all wars operate in this way. We’ve the past couple days seen reports coming out that have been quoted up to the State Department, to the spokesperson, of IDF folks saying that they are – their operation centers are shoot first and ask questions later. That’s chaos, but that’s not how war is conducted.

People saying that no one would shed a tear if they demolished a Palestinian home in Gaza, if they shot just for fun because they’re bored, this is not what war is usually like. And even if you look at the aid worker deaths, which are unprecedented, the journalist deaths, which are unprecedented, the number and scale – the pace of the food insecurity. Ninety-six percent of the population at IPC stage three is shocking. And to have had that happen within a matter of months is devastating. So war isn’t – doesn’t have to be this way.

I wanted to point out a couple of the things that both of you mentioned about safety. Sigrid Kaag has called for, in front of the U.N. Security Council, effective, credible, predictable, deconfliction systems. The fact that we’re nine months in and we’re still hearing that Israel is taking steps to do these things but hasn’t actually put it in place has a direct line to the aid workers that have died. And that’s not just Western aid workers. That’s many, many Palestinian aid workers. The fact that they’re still – Sigrid Kaag is still calling for route clearance from mines and unexploded ordnance – when people begin their movement back to their homes, which news reports are saying that they’re already doing in order to find things that they – you know, to gather their belongings, to look for their dead. The fact that they could die when they go back is tragic.

And of course, the fact that electricity is still at zero every day. It’s good news that Israel’s thinking about establishing some electricity for desalination to provide more water for people, but the fact that it’s been nine months and there’s still no electricity that’s coming in is – all of this is exacerbating a humanitarian situation that doesn’t have to be this way. So I think that’s an important tragedy to point out.

The other issue of people saying, what are we doing? What are we doing here? This place has no future. I think that this, again, is so tragic when you look at it in the context of what people in Gaza have experienced over the course of many wars – their fear of leaving their homes for fear that they can never come back, their sense that they’re being, you know, called – they’re being dehumanized, that their lives are not being – are being protected. All of this is just such a tragedy that it’s difficult to name how bad it is.

And the fact that funding is still short in these appeals, I think there’s so much more that could be done. Three hundred and three million (dollars) is how much short the WFP is saying their funding appeal is for Gaza. Governments could be doing more. The U.S. government could be doing more. European governments could be doing more to send money. And the fact that crossings are still – that Rafah is closed, and that more crossings in the south are needed to be opened, and there needed – the ones that are operational need to be open more predictably for more hours per day, to allow aid workers to provide that unimpeded access to aid, all of this – again, these are things that parties to the conflict could be working to fix. They are not unsolvable problems.

But the fact that political will is not there to do it, and that the U.S., that the State Department spokesperson, Matt Miller, just on July 8th was saying that the U.S. has been responsible for all of these humanitarian breakthroughs, in the context of a conversation happening today in D.C., where we’re sitting here in Washington, D.C., it is unacceptable that every single humanitarian breakthrough is being described as coming from the U.S. government, when the U.S. has such an important alliance with Israel, Israel has a responsible military that should be able to follow international humanitarian law and should be able to facilitate humanitarian aid – unimpeded, safe, consistent, predictable, humanitarian aid – in a war that they’re prosecuting.

So, yes, Hamas has made this extremely difficult in terms of the way they conduct operations. But I just wanted to make sure to emphasize that a lot of these issues could still be solvable.

Dr. Morrison: Thank you. Rik, your thoughts?

Dr. Peeperkorn: No, I think everything was reflected. I think that was a very good overview and analysis. Thank you for that.

And maybe, I think, you raised two things, Stephen, about, like, Khan Younis. And I think I’ve also heard it in – yeah, in what was said just now. People are moving in Gaza. So, for example, when – for myself, when we drove through Khan Younis, the last time I was in Khan Younis was in April, a number of weeks. And then there were no people. It was in the – well, the military activities, been there early February. Immense, immense destruction. There were no people.

I remember on Eid day some people came back – it was a beautiful Sunday – and we did an assessment. And then people were looking for their belongings. They came from Rafah. They were looking for their belongings, if their house was still there. Almost everything is destroyed then, and to take something. But they didn’t stay. They all went back. Now, in Khan Younis, you see many, many people. So people constantly move, because we know that Rafah, where there was a million people, the million people fled. So a lot of them are back in Khan Younis, and there are a lot of – and other places.

And my last word. I mean, I want to be not misunderstood. I mean, like this. I think on the access routes, of course, we argue for any access routes possible. The best way, of course, or the most cost effective. And I think made my point very clear, they are these land routes. And if you talk about sea routes, and maybe I’m oversimplifying this whole thing now, but I think we have to look at early recovery and rehabilitation and reconstruction. And we have to hopefully think about a ceasefire – a ceasefire process.

If you think about that, what about a port? Which has been the table for many, many, many decades. If you have a proper port which can function in a cost effective way, I mean, like, and I think that’s – I think, good. But I don’t want to go there. We have to start thinking about it. And I also don’t want to be too negative. When I said – I use the word desperate and depression, what we all go through. We are there so stay and deliver. And we will be there to stay and deliver. And also, when early recovery comes and rehabilitation and reconstruction, rehabilitation on the medical field will be also massive. Not just buildings and infrastructure, but also think about people.

Think about all the amputees. Mental health. We could probably have a whole – a whole session on that topic, on Gaza. There’s so many areas. And there’s so much already happening now, with the humanitarian presence – which I think is incredible. I mean, like, but specifically with the Gazans – the Gazan communities, and the Gaza health workers, the Gazan teachers, et cetera, et cetera. We have to make sure that they are able and they will be empowered and enabled to do their work. And, yeah, that they will find that we will help them, Palestinians, to come with an improved solution on the way forward.

It will be an incredibly long and complex road. I hope we will be able to coordinate as good as possible as well. WHO is very much ready for this and, yeah, we are also grateful that we are part of this overall response. Over to you.

Dr. Morrison: Thanks, Rik.

Cameron and Rik, you’re both, it seems to me, struggling with this idea of how to create security and protection for operations and, Cameron and Rik, it’d be good if you could tell us – give us a bit of a concrete illustration of how do you find a solution.

I mean, the stuff that was landing on the beach was trapped there for some time. Now it’s moved. What was the – and there were – you know, the IDF didn’t want to take responsibility. The World Food Programme was reluctant to pick it up and become a target.

But somehow it has moved to Gaza. It’s in the hands of WFP. What – give us a little bit more of how do you find – how do you craft a solution in this situation, and, Rik, I’d like you to add also, like, in practical terms what are the options right now? Cameron?

Mr. Hume: OK. Thanks a lot for that question.

I think – just to be clear, yes, it would certainly be better if there were a ceasefire and if there were order but there isn’t and we’re operating in a situation in which there is no ceasefire and people are hungry.

What my colleagues were able to do in conjunction with the operators of the JLOTS pier is they designed six different routes in order to move things from the beach. Of course, as Rik pointed out, it’s a less populated area. That’s true.

They were able to design six different routes, and so it was never clear to an observer or someone in Gaza exactly which route would be used for moving the supplies from the beach to the WFP warehouse and I think that this was part of the reason they were more successful.

They didn’t have to move on a specific road through a heavily, densely populated area and so it was – they had better odds.

Is there a perfect way to do this? Absolutely not, and, yes, I mean, it is a – I don’t think that all wars are chaos but this war is a chaos. That’s what we’re operating in, a lack of – fundamentally a lack of a recognized legitimate order.

Hamas bears much of the responsibility for that. But, in any event, I don’t think there’s an easy answer. One has to be super prudent and do the best one can.

Dr. Morrison: Rik, tell us – give us an example of how you’ve gone about trying to incrementally change the picture in terms of security and protection.

Dr. Peeperkorn: Yeah. Stephen, I find it a very difficult question, especially if you ask a WHO staff member, a medical doctor, and public health specialist. But I will – I will try.

I mean, I just – so I find this difficult, but I think – I think I agree with what I heard from Cameron about the chaos and the chaos which is there, and so who is operating this chaos. I completely – that’s what I’ve seen on the ground and this is what is, unfortunately, increasing.

I think as long as – and there, so, actually, similar to what Cameron said, as long as this war is going on and there is this chaos, the parties to the conflicts – and we know who they are – they have an obligation. They have an obligation to help ensure there is security, and at least basic security and basic law and order – public order. And the member states which have influence and contacts to these parties to the conflict, I think that should be constantly on the table.

What will be there – (inaudible). And if there is no blue police, what kind of other mechanism could be – could be strengthened? Could it be communities? Could it be the – could it be community leaders? Could it be a group of community religious leaders? Could it be something else? Could it be – but somehow, that has to be strengthened. And that sometimes also goes hand in hand, as we know in policing all over the world, with police with arms. So I think the – it’s not just the parties to the conflicts which have to realize that – I mean, to work on that. I think also anyone who – member states who can influence that process.

Of course, when you come to a ceasefire processes or peace processes, and I also hope that the parties of the conflict, international community, will assist. I mean, and this is – and some of you have been – I’ve been also working in other conflict areas. This is not completely new, et cetera. And I’m sure that that organizations and people – real specialists – better specialists than me are already reflecting and analyzing the thinking about that. But we all – we all will agree that the basic public order and safety is key for everything. So that would be my answer, Stephen. Over to you.

Dr. Morrison: Michelle, we’re – you know, if you read the IPC, and the nutritional analysis, and some of the other projections and forecasts that are being made – it’s July 10th today. In six weeks’ time, we’re going to see accelerating mortality. If things stay on the current course – even with the greatest determination by brave and committed humanitarians and health workers, in the current circumstances if things continue as they are we’re going to see accelerating mortality in the September/October timeframe, that will be much more visible, I would expect.

You make the case about the rules of war and the obligations of the – of the combatants, Hamas and the Israeli Defense Force. What should the U.S. be doing now, as we – as we stare at this prospect of what lies ahead? We’re already in, as we’ve heard from Rik, an utterly devastating situation. But it’s going to get worse.

Ms. Strucke There’s so many things I think the U.S. should be doing – from not being distracted by the whether or not a famine is officially declared, but looking at the fact that 96 percent of the population is in need of food, in need of nutritious food, in need of being able to receive the food – not just drop off the food, but actually receive the food. The U.S. should certainly be continuing to push for the ceasefire, doing everything they can with their influence over, you know, Israeli counterparts on the defense side and on the political side to push for a ceasefire.

And additionally, taking a very hard look at things that are in their control, like more funding, to be able to deliver and meet the shortfalls that the U.N. agencies and humanitarian partners are trying to deliver, so that they have what they need. And certainly, taking a harder line on humanitarian access and protection. This is something that we’ve seen. The fact that the U.S., in some limited circumstances, has been willing to use the hardest level of pressure – which is withholding particular munitions from the Israeli Defense Forces – when Israel is demonstrating that they are going to use those in a way that is irresponsible in terms of the civilian population.

So the U.S. should certainly be using those – continue to use those pressure points to ensure that more steps are taken – more crossings are open, they’re open for greater periods of time, and that they are not distracted by the fact that March and April gains allowed the predictions to be slightly less worse from the IPC than expected. As you’re mentioning, given the fact that since that time Rafah’s been closed for two months and we have, again, nowhere near the level of aid that is needed to be reaching the population. Don’t get distracted by that and think things are going better, when they’re actually going worse.

So quite a few things the U.S. has in their power. And focusing on important issues, like deconfliction, provision of fuel, and continued push to restore electricity – these are some of the things that should be – should be top of the agenda.

Dr. Morrison: Thank you, Michelle.

Cameron, Fogbow jumped in on this initiative, in part encouraged by the Biden White House, back in the earlier part of the year. What is it that you need now? As you you’re facing a decision point on whether to build a pier after the JLOTS goes away, you need the concurrence – you need the cooperation of a number of different players on the ground, including the occupying power and including their partners in the U.N. and other NGOs, and Palestinians involved in the marketplace or in the thinking about industrial rehabilitation. What is it that you – what is your message to Washington policymakers?

Mr. Hume: Well, I think we’ve been – we’ve been able to get a lot of cooperation, certainly on the funding side, from some countries in the region. We have an intense dialog with the authorities in Israel, because we understand you can’t get food, you can’t get supplies into Gaza, without cooperation with COGAT, or without the approval of COGAT. I think that one of the challenges – and I think we heard this today. One of the challenges that we’ve faced, honestly, is how to get acceptance of, essentially, a private organization operating in a space which has been reserved for other actors.

I know from my professional work working with a private organization to end the war in Mozambique, I know from my service in Sudan working, again, with private organizations in order to speed relief supplies to Darfur 15 years ago, and I know from working on the AIDS issue in South Africa when I was ambassador there, private organizations can play an important role in some areas of humanitarian need. And I think this is one in which a private organization can possibly provide some facilitation, some assistance that’s not as effectively provided by other organizations.

Dr. Morrison: What more do you need from Washington to be successful?

Mr. Hume: Well, I’ll make a brief comment. I think that – I think that they have to succeed in articulating and on implementing an overall policy towards Gaza so that there would be a clear framework. That should start with a ceasefire. Obviously, most of their efforts have been to get a ceasefire. But the ceasefire has to be attached organically to a peace process that gives some hope to the Palestinian people. And that’s what we hope to be – we look at rehabilitating the Gaza industrial estate or other elements of the civilian infrastructure in Gaza. That’s the future we look forward to.

Dr. Morrison: Thank you, Cameron.

Rik, we’re getting to the end of the hour. I’d like you to be able to sum up for us your closing thoughts on where to go from here. I think having Dr. Hanan Balkhy come with you within Gaza and West Bank, a terribly important measure. I think the secretary-general’s engagement, Ambassador Kaag’s engagement is giving visibility and – greater visibility into the dimensions of this than we’ve had before. Share with us your thoughts on what needs to happen next.

You’ve laid down the specific areas of your asks. How do those asks move forward? What – you know, who are the main actors, in what context? Is this something the Security Council needs to simply stay with and keep moving forward? Or what is the – what is the forum? We have a NATO summit here in Washington this week. I don’t think we’re going to be talking much about that. But share with us your thoughts on what more needs to happen to carry forward these very specific asks that you laid out.

Dr. Peeperkorn: Yeah. I will try to do my best. And thank you very much. And thanks also Michelle and Cameron.

I think the first, overall, which I should have started with, I think Cameron and Michelle were also, of course, raising it, is, of course, a ceasefire. And I think a ceasefire, peace process, whatever you call it, I think everyone has a little influence. Some have more influence on those processes. And I think it’s – hopefully, it will be used. And, of course, also the two parties of the conflict play a role there. I mean, like – and, but that’s, of course, the first – the key – the key overall ask.

I raised – the second ask which I raised was protection. And I just want to mention, it’s just not for health. But looking at health for us it’s specific – and, again, you – initially it’s the parties to the conflict, but also anyone who can influence the parties to the conflict. You want to protect your – if you focus on health – health should never be a target. So the health facilities, the hospitals, the ambulance, EOCs, et cetera, anyone who operates facilities, health workers, et cetera, they all need protection, including them.

Then the medevac. I was quite specific on that. There is ongoing discussions on that. And we really – we really want to see these corridors established, and that a regular medevac process will take place. And again, WHO is very much ready to support/facilitate/coordinate that process, and I mentioned what and how. Again, that is not only the parties to this conflict; it’s also the countries around to facilitate and support that.

Then the medical supplies. And maybe one – another issue which we are also discussing, and we had a discussion with the partners but also with – we already named COGAT. We have been discussing that as well, medical supplies and equipment lists now and for in the future.

Where we want to go through is, of course, there is – there’s a lot of WHO standard lists. We know approximately what the needs are per quarter for essential medicine in Gaza. We know – we estimate what the needs are in medical supplies and equipment.

Now, when they’re part of WHO’s standards list globally we use them everywhere, everywhere around the world in our conflict areas, et cetera, and there should not be questions again and again and again and delays, processes, et cetera. So it’s something we are pushing right now, and we need all the support for that as well.

The other areas which were mentioned already, I think, by Cameron – and I’m not going to repeat our access issue, the fuel, comms, EV. You know mentioned that. That’s just a very general point.

So this would be my – we have the key focus, and I would say that the key ask and the way we want to approach them. Over to you.

Dr. Morrison: Thank you, Rik.

We’re at the end of our hour. Michelle, did you want to add any closing thought?

Ms. Strucke: Just to say that this is such an urgent time. Just between July 4th and 8th a hundred and eighty-two Palestinians were killed and 458 injured. Four schools were hit in four days, schools that people were sheltering in that should be a future for Palestinian children and instead are places of death and destruction.

This is an important, decisive moment, and as the U.S. continues to push for a ceasefire it is absolutely critical that they are clear eyed about red lines for humanitarian assistance, lines that are affecting the human population of Gaza for generations to come if they don’t act now.

So it’s easy when it’s just been going on for nine months, longer than anyone I think predicted it would go on, to have a sense of cynicism. But I believe in policymakers’ ability to make changes happen and so I would call on them to do more.

Dr. Morrison: Thank you. We’re at the end of our hour.

I just want to thank Dr. Rik Peeperkorn, WHO-occupied Palestinian territories for your commitment and your courage and determination and for spending an hour with us here today.

I want to thank Ambassador Cameron Hume for his work in carrying forward the Blue Beach plan and the progress that’s been seen recently in the distributions into Gaza City, and, Michelle Strucke, thank you for joining us in this partnership here.

The video and transcript for today’s discussion will be posted on the CSIS home page today. That’s CSIS.org. Thank you so much and, again, thanks – special thanks to the production team and to my colleagues in the Global Health Policy Center.

Thank you.