Gaza: The Human Toll

This transcript is from a CSIS event hosted on November 13, 2023. Watch the full video here.

Stephen Morrison: Good morning/afternoon/evening. I’m J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies – CSIS – in Washington, D.C., where I direct the Global Health Policy Center.

Today’s live studio conversation “Gaza: The Human Toll” is hosted by the CSIS Bipartisan Alliance for Global Health Security in active collaboration with the CSIS Humanitarian Agenda and other programs and experts. The show will convene regularly during the crisis to capture clearly and accurately the evolving humanitarian and health situation inside Gaza.

I’m joined today by Dr. Rick Brennan, the regional emergency director for WHO’s Eastern Mediterranean Region. Rick is an emergency and public health physician who has worked in health emergencies in over 35 conflicts. We’re very grateful that he’s making time out of his day to be with us today. We’ve had the pleasure of working with Rick in many other conflicts.

We’re also joined by a close colleague, Michelle Strucke, who just recently joined CSIS as director and senior fellow of its Humanitarian Agenda Program. Throughout her career, she’s focused on humanitarian affairs, human rights, and development issues at the intersection of conflict. From 2022 to ’23, she served as the first deputy assistant secretary at the Department of Defense responsible for global partnerships.

We’re also joined by a close friend and colleague and a fellow of our program, Leonard Rubenstein. Len is professor of practice and director of the Program on Human Rights and Health in Conflict at the Johns Hopkins University Bloomberg School of Public Health. He published in 2021 a landmark study of health and war entitled “Perilous Medicine: The Struggle to Protect Health (Care) from the Violence of War.” And we had the pleasure of hosting the rollout of that book here at CSIS.

Special thanks to my colleagues Sophia Hirshfield and Michaela Simoneau for all their hard work in pulling this together in a very short period of time. And special thanks to the production team that put this – is putting this event together: Dhanesh Mahtani, Qi Yu, and Dwayne Gladden in particular.

Before we begin, just a few framing remarks. As we all know and as we’ve witnessed increasingly in recent days, a massive humanitarian and health catastrophe has emerged in the Middle East in just five weeks.

October 7th, Hamas murdered 1,200 Israelis and took 240 hostages. Those hostages remain under Hamas control. It was a horrific pogrom unlike anything seen since the Holocaust.

Almost immediately, Israel laid siege to food, fuel, water, electricity, and medicines for the 2.3 million Palestinians in Gaza. That was followed by an aerial campaign on a scale and intensity not seen in wars in recent decades, with widespread reports of indiscriminate attacks on civilians. In recent days, ground operations have begun in the north, in particular marked by intense urban combat.

The Israeli stated aim of the war is to destroy Hamas military and governing capabilities. Fundamental to its war efforts is the assumption that Hamas’ network of tunnels, especially in and around Gaza City, house its command centers, communications, stockpiles of weapons. And as we’ll hear in our conversation, this has had consequences in how the interpretation of international humanitarian law, rules of war, apply in this instance when we’ve had attacks upon hospitals and health clinics and ambulances and the allegations around these being legitimate targets versus ones that need to be protected under humanitarian law.

Where do things stand today? Hamas still holds 240 hostages, and Gaza is at a breaking point, unsafe anywhere; 1.7 million Gazans displaced out of a population of 2.3 million, over 11,000 reportedly dead, of which 40 percent are children. That’s an astronomical number by any war context; 27,000 injured.

North Gaza, as we see on the television and in social media, is beginning to resemble Aleppo or Grozny or Mariupol. Unknown numbers are still in the north, inaccessible. Twenty of 36 hospitals no longer function; two thirds of primary health-care facilities closed; 108 attacks on health facilities; running short of anesthesia, medicines. People are drinking non-potable water. Sewage and desalination facilities are at – have halted. This will lead rapidly to unthinkable levels of runaway illness and early mortality.

The Rafah corridor has been open, and approximately a thousand trucks have passed through that at an average of 30 to 50 a day. Prior to October 7th, the flow was 500 a day. And the needs now are well in excess of 500 a day.

International organizations like WHO and other U.N. bodies and International Committee of the Red Cross and international NGOs like MSF are not protected. They’re not exempt from the dangers on the ground. At the end of last week, UNRA had lost over 100 staff members, the largest loss in U.N. history. And there was a memorial, a moment of silence, in their honor earlier today.

What to do is what we’ll be talking about today. This is war. War causes humanitarian crisis. All parties to conflicts, state and nonstate, are obligated to adhere to international humanitarian law. How to make that happen is a huge challenge. We’re hearing louder and louder calls for humanitarian ceasefire, for larger numbers of trucks and expanded numbers of access points. Negotiations are off-on. We’re not certain about the release of the hostages.

I want to now turn to Rick Brennan, Dr. Brennan, to open things up with eight to 10 minutes of remarks. Following that, we’ll hear from Michelle Strucke and Len Rubenstein. And then we’ll have a conversation among us.

Thank you so much. Over to you, Rick. Thank you for making time out of an extraordinary schedule to be with us today.

I’m not hearing him.

Rick Brennan: Sorry, I was muted.

Stephen, thank you. It’s a real pleasure to be back with you and an honor to be on the same panel as our old friend Len Rubenstein and our new friend Michelle.

So, I mean, I think you’ve captured the issues extremely well from a humanitarian perspective. And maybe just to frame things, I mean, I would say the last couple of years, even the last two months, have been perhaps the most challenging period in the career of almost all the humanitarians I know, particularly in this region. I’ve been working in humanitarian assistance for 30 years.

Since the start of the pandemic, the number of people needing humanitarian assistance globally has more than doubled. I mean, that’s extraordinary. And that’s not because of the pandemic. It’s on the back of conflict in places like Sudan and Afghanistan, Ethiopia, and Ukraine and so on.

So just in our region right now, 23 – 13 of the 22 countries that we support are receiving some sort of international assistance for a major crisis. That’s just extraordinary. And we have, across the 22 countries that we cover, 38 percent of the global humanitarian burden. And that’s just going up as we speak.

The situation in the occupied Palestinian territory, the situation in Israel, I mean, are a particular crisis. And you used the word catastrophic, and I couldn’t agree with you more. I rarely use that term. I certainly apply it to what’s going on in Gaza right now, as well as what’s going on in Sudan. And as you rightly said, war has humanitarian consequences. It has health consequences.

And just picking up on the data that you’ve already presented, we don’t have the recent data. I mean, the Ministry of Health, often called the Hamas-controlled Ministry of Health, has been accepted as collecting and reporting reliable data over years. It stopped reporting as of the 8th of November.

So the data that we have as of then, around 11,200 deaths, around two-thirds of which are amongst women and children. Normally, we would expect around, you know, 60 to 70 percent at least to be amongst adult men, so that’s an extraordinary statistic.

Over 28,000 injuries, and these aren’t just simple injuries. These are complex war injuries – burns, amputations, terrible head and chest injuries – and often associated with what we call mass-casualty incidents where multiple trauma patients are brought to our facility at a given time.

Over 1.7 million people displaced, and a large proportion of those now crammed into these terribly overcrowded schools and collective centers run by UNRWA, where they’ve got very limited access to clean water, sanitation. Their toilets are overflowing. There’s open defecation. And there’s constant bombardment. And some of the testimonies we’re hearing from our colleagues and families of colleagues are just extraordinary.

Now we’ve got 22 of the 35 hospitals completely nonfunctional, and those that are remaining to operate are doing so at well below their capacity. So most of the beds, around two-thirds of the beds in Gaza, are in the north. And, of course, there is where we’re seeing the decline in functionality of health facilities and, of course, mass movements outside of the north down to the south. So our bed – our bed capacity and our ability to meet the health needs of the population is plummeting as the needs are absolutely soaring. That’s a huge problem.

Prior to the conflict, we estimate that Gaza had around three-and-a-half thousand beds. We have probably lost at least two-thirds of those right now. And we’re trying to deal with this massive medical need.

So what are WHO and our partners trying to do right now? Well, it’s an incredibly difficult operating environment, as you can imagine. We have 24 national staff on the ground. We have only just now been able to return some of our international staff over the last 48 hours.

Our big focus, of course, has been helping the health system to respond to the massive trauma needs by bringing in supplies and equipment. We’ve already done a lot of training over the years. And then also sustain access to other essential health services – making sure that the 180 women that will deliver each day in Gaza have access to obstetric care. We expect about 15 percent of them may need a Caesarean section or have some form of complication. And where do they go right now, with this major decline in the availability of health services?

You know, people with dialysis. There’s over a thousand patients with dialysis, kidney failure in Gaza. Those dialysis services are progressively declining in functionality, and a lot of those patients will die as a result.

The 9,000 patients that have cancer who’ve had their cancer therapy disrupted, you know, put at high risk. And we can fully expect that a number of them will die.

I can talk a little bit more, perhaps during the discussion, about our strategy now to transfer beds, expand capacities of existing health facilities, medevac patients out into Egypt. Only about a hundred, a hundred and twenty patients have been medevac’d right now. We need to scale that up. We need to scale up the capacity of the remaining health facilities, perhaps start putting inpatient capacities into primary health-care centers. And of course, complementary field hospitals on a small scale. We haven’t got one field hospital committed at this stage from our partner network, but that will be part of the options as well.

So trauma care, access to essential health services. We’ve also got to scale down disease control because of the lack of water, poor sanitation, overcrowding, disruption of health services, cessation of vaccination campaigns, and so on. We’re already starting to see increases in respiratory infections, in diarrheal disease, internal skin infections like scabies, and so on. So the risk of outbreaks is also extremely high.

Mental health is a huge issue, as it is in Israel. And I should, you know, preface my remarks that I was only going to really address the health and humanitarian issues in Gaza, and I can touch on the West Bank. My office does not cover Israel. We’ve got another office is covering Israel. And I don’t want to diminish at all the huge health – psychological impact of the horrors of October the 7th in Israel. We certainly acknowledge the horrors that they’ve been through as well.

So, you know, we’ve got a lot of work to do. I mean, one of our big challenges is just getting the supplies in. We’ve set up an operational base in a place called El-Arish in the northern Sinai. That’s a militarized zone. We as international agencies have very little access there. We’ve only got one staff member who’s finally been allowed on the ground there about three or four days ago. So trying to run this big logistics operation from there, bringing the supplies across the border with 100 trucks a day – which you mentioned, Stephen – which are well short of the 500 that we think we need. We’ve been able to do four major distribution of trauma supplies and medicines for chronic diseases, orthopedic equipment, and so on. Twice we have been able to get to the north, including to Al-Shifa, which is the biggest health center. And of course, now its capacities have been drastically reduced.

Huge operational constraints for us. Our 24 national staff, they’re all shell shocked. They’re doing a heroic job, as are other health-care workers and other humanitarian workers. Massive insecurity. Nowhere is safe in – across Gaza right now. Our access to the north has essentially being cut off, and we expect within days that the health system will, you know, largely stop functioning in the north, putting a huge burden on the south, again, with insufficient resources.

Fuel is a massive, massive need. It’s not getting in. Hospitals are closing because of the lack of fuel. Ambulances aren’t working. Desalination plants aren’t working. And in fact, like, just before you introduced me, Stephen, I got a popup message from our logistics colleagues to say UNRWA will not be able to do the distributions of the supplies arriving in Gaza because their fuel has run out. So our ability to deliver right now, horrific. And our partners – just about every one of our NGO partners has stopped operating in the north.

I do want to say something about the conduct of this conflict, and a lot has been said about adherence to an international humanitarian law. A lot has been said about principles of conducting a war – you know, the principles of proportionality, of distinction, of precaution. We have grave concerns about – as does the U.N. across the board – about the way that this conflict is being conducted because of what – because of its humanitarian health consequences and, of course, other considerations.

But if we look at the way that that the – you know, some of the statistics that – again, over 11,000 deaths, and more than two-thirds of those amongst women and children. That does not normally happen in a conflict like this. It just doesn’t. It’s usually, you know, adult men.

Secondly, over a hundred humanitarian workers killed, highest number ever.

Thirdly, over 30 reporters killed, highest number in a conflict ever documented, as I understand it.

And you know, as I mentioned, just a couple of days ago we finally got one of our staff – international staff into Gaza, and he stayed at a UNRWA compound in Rafah along with seven other U.N. partners. They left yesterday morning for – you know, to start their workday, and that dwelling was struck by three – by two shells, doing severe damage to that dwelling. And if they’d been inside, they would have – there would have been deaths for sure. That was the second U.N. compound shelled within a 24-hour period. The UNDP compound in Gaza City was shelled and there were deaths. Fortunately, yesterday in showing the compound where our colleagues were staying – (inaudible). So, we do believe that the conduct of this conflict presents grave, grave concerns with respect to the adherence to international humanitarian law and a sense of humanity.

What we want moving forward? Clearly – we’re humanitarians – we want a ceasefire. There is not going to be a military solution to the problems that beset Gaza and the occupied Palestinian territory in the views of many, many people. We understand the Israelis have, you know, a duty or a right to defend themselves. But, again, the way that this operation has been conducted raises grave concerns for us.

We want unhindered access to those in need. And there are – we’d even – or I would say that the whole 2.2 million population are in need right now.

We want unconditional release of all the hostages. While they remain in captivity, they should have access to health and other services, of course.

And we want respect for international humanitarian law and for health facilities. There’s been over 120 attacks on health in Gaza. That’s another aspect of the conduct of the conflict that I omitted to mention, but I’m sure many, many people – (inaudible).

So I’ll just say, again, thank you for the opportunity – maybe I went a couple of minutes over – but for the opportunity, and happy to engage in the discussions.

Dr. Morrison: Rick, thank you so much for such a comprehensive and rich and powerful overview, and I’m glad you were willing to take a few extra minutes in order to do that.

I just want to say that you and Dr. Tedros and Mike Ryan and other WHO leaders have shown profound courage throughout this period. You’ve had a very, very strong voice – consistent voice. You’ve stood your ground on principles and shown remarkable operational courage in the deliveries and under extraordinarily dangerous circumstances through this period.

So we’re really – we’re really grateful to what WHO has done and shown itself capable of doing in this period under such extraordinary adversity and danger. I commend you and all of your staff for what you’ve been able to do.

We’re very lucky that Michelle Strucke has chosen to come to CSIS to be with us to lead the humanitarian agenda program and that we’re now able to collaborate in this fashion.

So, Michelle, I’m going to ask you to open with some remarks and then we’ll turn to Len.

Over to you, Michelle.

Michelle Strucke: Thank you so much. I’m grateful to be here and I want to echo what you’re saying about the WHO and other U.N. organizations having great courage at this time.

The rhetoric, as we’ve seen, has displayed, I think, a level of horror on all levels. We’ve seen the horror of the people that are experiencing this crisis. That is exceptional for so many reasons. We’ve seen the horror of those that are watching it on their television screens, their social media, their phones.

We’ve seen the horror of those that are neighbors to this conflict that are – you know, I’ve heard that people in Israel some of them can hear the attacks that are happening and that does something to people’s psyche. So we are in a situation which is horrible for everyone that is touching it. So I wanted to start with that.

In terms of, you know, some things to share. that Gaza before this crisis started was already a place that was blockaded. It was already a place with limited access to humanitarian supplies. We saw 500 trucks that were going in per day. There’s been a lot of discussion of trucks.

The period of time where there was no trucks allowed in, if you think of that, that was actually causing a backlog at the very greatest time of need when bombing was the worst in Gaza. We saw needs not being met, and now, even now, which is reporting that only 981 trucks have entered since October 21st it’s far insufficient to meet the humanitarian needs that were already high in a place with, you know, repeated conflicts where the system itself – the health care system, as we heard, was already fragile, had to build up a sense of conflict-based resilience to turn, like, hospital facilities that weren’t prepared to be.

For example, a tertiary facility like Al-Shifa had to actually transform themselves into a more resilient architecture. All of that we’re watching get shattered.

And also before this happened Gaza was a lower middle income economy. It was an economy where you had people that were college educated. They had hopes. They are people that were creating an emerging, thriving tech sector that was being invested in by some of the Silicon Valley major tech companies. It was a place where, despite these repeated conflicts, you saw hope and resilience that, at the moment, when we turn on the news we see devastation. So I wanted to share that this is a – it was a place of need, but it was also a place of great resilience and hope.

And it was also one of the most densely populated places on Earth, and still is. So as we see population dynamics shifting and people moving from the north to the south, you went from having an area like Gaza City, that was the most – one of the most densely populated cities on Earth, more even than New York City. You’re seeing that now shift into the south. And that’s causing, obviously, overcrowding, which has huge humanitarian consequences. Also to share, and as we keep hearing over and over again, nowhere is safe.

As people are being asked to evacuate, as they’re using these nascent humanitarian corridors to get to locations of safety, there’s still active conflict going on in those places that is causing them to feel that there is nowhere that they can go that would be safe. And so I wanted to share that that is an extremely important part of the humanitarian access piece here, that in a conflict where you have siege tactics – which still are supposed to follow the rule of rules of war – people feel that they can’t trust that when they’re being asked to go to a place that they’ll be able to have safety when they even get there.

Some other aspects of this – of this conflict that I thought were important to mention, were that all of the decisions that if you – if you put yourself in the shoes for a moment of a person that’s trying to – that’s caught in the middle of this crisis, that’s trying to flee, they are carrying on their backs the weight, essentially, of generations of people that had to make similar choices about whether to flee. And that psychological toll, I think, is very practically – we’re seeing it play into people’s decisions about whether they evacuate, do they remain?

And I don’t think we should underestimate as well the power of the Palestinians that are impacted by this, of their will to remain in their own – on their own land. And I think that is a very significant thing where we’ve seen even tweets, for example, from Palestinians saying things like: I want to return to my home and sleep there tonight, even if I’m sleeping on the rubble. So there’s a really powerful desire and history and context that I think we just have to mention as we’re considering the humanitarian choices people make about do they comply with an order, are those orders that – those evacuation orders that Israel has given, are they adequate and fair to give them enough time to actually get to where they need to go or not?

In terms of the situation of children, I wanted to take one moment on that. We keep hearing in this conflict – and Rick said it very well – that so many parts of this are exceptional. The number of U.N. workers that have died. The number of journalists that have died. And the number of children that are dying per day. Four hundred and twenty children in this conflict are dying, per day. That number really blows any other number out of any recent conflict out of the water.

When you think about that, Rick mentioned that WHO says that 183 births happen per day in Gaza. Four hundred and twenty children are dying each day. That means more children are dying each day in Gaza than are being born. Save the Children recently reported that, you know, in 2021 the average in conflict zones worldwide was 22 killed per day. And we’re at 420, in a population which is largely comprised of children. So this kind of situation, again, is so exceptional.

And yet, from an international law perspective, and I hope we’ll talk more about that, the norms of international law are meant to apply everywhere. They’re not meant to be, you know, kind of changed based on a party’s perception, of course, and their conviction that their war is just. So this exceptionality we’re seeing in devastation, but we should not be seeing in the way that the war is being conducted. So I wanted to mention those things.

From a humanitarian standpoint, it’s really – it’s so stunning to me, coming from working inside the U.S. government, where I saw my colleagues every day really devote every second of their time to trying to help people in need when that was called upon – the U.S. was called upon to do so. I can’t imagine how difficult it is for my former colleagues now, as they work on this, to watch these things happen and to try to help.

But I do hope that we spend some time talking about U.S. policy issues, because the U.S. has been playing a very powerful role here. While they can’t control the actions of the government of Israel, there’s certainly some – a range of choices of things that U.S. policy officials could be doing to try to get assistance in. So I’ll stop with that, but hope to – hope to discuss that as well.

Dr. Morrison: Thank you so much, Michelle.

Our third speaker is Len Rubinstein, close friend and ally in many of these various conflicts that we’ve found ourselves working on over the years. Len, thank you so much for joining us today.

Leonard Rubenstein: Steve, thanks for having me. And thanks to Rick and Michelle for your compelling presentations.

One fact I’d like to add is the intensity and short duration of this conflict. In a mere five weeks, there have been 14,000 Israeli strikes on targets in Gaza. And we’ve heard the toll. And the toll, I think, not only includes the civilians who were deeply harmed, but the law itself. The law of war is premised on one major idea, that civilians and other noncombatants must be protected. Hospitals must be protected not only from targeting, but from harm. So the harm to them must be minimized in any military operation.

I think, from what I can gather from statements made from the prime minister down to military spokespersons when they are asked about attacks, they always cite the rule of minimization of harm. And they also cite the rule that proportionality must be adhered to in attacks. That is, that the excessive harm to civilians can’t be outweighed by the military objective. But the subtext, and sometimes the explicit language, suggest an entire different conception of what law of war means comes from Israel. And that idea is that in a just war, civilians can be sacrificed.

And it derives from a theorist of war back in the 19th century that influenced and actually wrote a code for the Union Army in the Civil War. His idea was that the exigencies – that civilians and hospitals can only be protected as the exigencies of war allow. That means, any amount of harm can befall these civilians, and hospitals, and health workers in the name of winning a just war quickly. His views have not been adopted. It was the Geneva Conventions and its idea of humanity and civilian protection that prevailed. But I am increasingly concerned that Israel may be adhering to that view by Francis Lieber, who advocated this different and very non-protective position.

And I can give you three very brief examples. One is, the law requires that you don’t attack any civilian utilities – water, power, sewerage. And we’ve seen, in Ukraine, for example, that Russia was called task, condemned, for its attacks on the electrical grid last winter. Well, the same goes if you don’t attack it through missiles but by turning off the electricity. And the only justification Israel has provided is they’re trying to provide Hamas of electricity. So they’re ignoring the civilian impact in the cutoff of electricity.

Second is the question of minimization of attack. That goes to precautions. And most precautions are about military means, whether it’s a ground or an air attack. When the attack is made, what kind of ordnance? Is it a 2,000-pound bomb? Is it a more targeted and smaller weapon that achieves the objective while preventing civilians from harm? And those rules are applicable in every single attack. When you hear the response from Israeli spokespeople about attacks, they cite one thing only. They cite, we told people to evacuate. We told you to get out of there, and you if you didn’t it’s basically your problem.

That’s not really a precaution. That’s a warning, but that doesn’t cover any precautions and it never cites specific precautions. Maybe it’s trying to take them. You would think if they were, they would state them publicly.

And the final rule I’d like to just touch on this idea of proportionality in attacks. And what Israeli spokespeople always say is that the existential threat to Israel from Hamas is so great, that every attack objective, to destroy a commander or a tunnel, or weapons, always exceeds – always exceeds – whatever excessive harm there is to civilians. So basically, it throws the proportionality rule out the window.

Some former members, lawyers for the military have said this explicitly. It's a little more couched by Israeli military spokesperson. But that is the message: We have to destroy every element of Hamas, every position of Hamas, every tunnel of Hamas. And I think what you end up with is all civilian harm becomes justified.

Dr. Morrison: Thank you, Len.

I'm going to go back to Rick and ask Rick for his – any thoughts in response to what we've just heard. Rick? Rick, you're not on.

Dr. Brennan: I’ve done it again. Sorry about that.

No, I think Len and Michelle have captured the issues extremely well. And you know, I have heard the Israeli government officials, you know, say that proportionality is not an accepted, well, principle, as Len indicates. But as he also indicates, the principles of precaution and distinction still apply. And so it's just extremely concerning, the level of distraction, the number of civilian deaths, and again, the age range of those deaths. I did a study 20 years ago about the age and sex of people killed in conflict, and at that time, you know, consistently over two-thirds, you know, sometimes up to over 90 percent of those killed in conflict were adult males, primarily men of fighting age. But, you know, the age and sex distribution of deaths in Gaza right now is not too far off the normal age and sex distribution. I mean, that's an incredibly concerning observation. I mean, that's just – you know, and the fact, again, that we’ve had the over 100 humanitarian workers killed. We have never had anything like this. And Len’s point is really well-made. Not only is this occurring; it’s occurring in a remarkably short period of time.

Perhaps the last thing I might say is that, you know, we know about the dates, and we know about critical infrastructure being disrupted. What we're not hearing is the personal stories about infrastructure as well. So the wanton destruction in some areas is also terribly, terribly concerning. So for example, one of my colleagues on my staff, she's Palestinian. She has a Ph.D. in public health. Her father and her sister are both pharmacists. She, her parents, her sister, who have, you know, nice homes in Gaza, they own two pharmacies, every home has been destroyed. The pharmacies are gone. Their vehicles are completely destroyed. To what end? I mean, we hear a lot about collective punishment. You know, these were not valid targets for a military objective, destroying pharmacies and homes of, you know, upstanding citizens. But this is happening far too much across Gaza right now.

Dr. Morrison: Rick, may I ask you a question? What's the significance of the four-hour pauses that were introduced, and what does it mean to be looking at a situation of the doubling of the population – already a dense population – but the doubling of the population in the south and the closure of all of these hospitals and the turn – the need to turn back at least in part to field hospitals? What's the significance of the four-hour pause in your view? And what does it mean to be starting to talk about field hospitals?

Dr. Brennan: So I think the objective, the primary objective of the four-hour pauses, is to get people, you know, out of – out of the north, and that hasn't always been safely done. People have been encouraged to move south. We've all heard stories of people being killed on the way, again, nowhere being safe. So now we have these four-hour pauses for people to move, and a lot of the time, they have no clue where they're going to end up. So the Israeli authorities, also with some support from the American government, they’re saying we have to set up a safe zone where populations can be moved to. We do understand from a briefing that U.N. partners received here in Egypt today that the offensive will soon start in the south. It won't be at the same scale, but it will be starting. And so there will be more population displacement in the south. People are being encouraged, you know, perhaps forced into a safe zone; what we understand, it’s being reserved for around 48 square kilometers. It will not be possible – if that is the case, if the objective is to move people into these tiny safe zones, it will not be possible to meet humanitarian standards for food, water, shelter, sanitation, and health care.

I mean, we all know about the Israeli claims of the militarization of health facilities. We've heard it particularly in relation to two of the health facilities. They imply perhaps more. What we are gravely concerned about is trying to move people away from the existing health facilities. We need to sustain that health system. There's going to be an end to this conflict, eventually. We need a health system that is going to be sustained. So rather than come up and set up, you know, and have the answer the health needs of a whole bunch of field hospitals, which won't be possible – you know, you can't have 3,500 beds replaced by 350 field hospitals, that's just not doable – we need to ensure that resources that are coming into the Gaza Strip for healthcare are used to stabilize and expand the capacities of the existing hospitals themselves. That's a real challenge. We're going to have to evacuate some patients to Egypt. We may have a small select number of field hospitals. And we're also hearing about hospital ships. But there's this – you know, any suggestion that field hospitals are going to be the answer to healthcare delivery in Gaza, they simply cannot meet the needs and they're inappropriate, they’re expensive, they’re an inappropriate diversion of resources away from stabilizing and supporting the system of health infrastructure.

Mr. Rubenstein: Steve, can I have one thing?

Dr. Morrison: Yes, please, Len.

Mr. Rubenstein: In terms of the law, I think it's important to mention that Hamas has contempt for international law. It had contempt, obviously, in the slaughter of civilians. It has contempt in triggering a humanitarian crisis, which was what they have themselves said. It's contempt in using and putting military facilities in hospitals and other civilian locations. We don't know if they were in Shifa or not, but they certainly have done that in the past. And that exacerbates the humanitarian crisis, and we should not ignore that. But of course, what it leads to is Israeli lack of compliance, and we get into a downward spiral. And it's one of the fundamental rules of international humanitarian law that violations by one side never justify violations by the other, because you have a downward spiral to barbarism. So we have this terrible, non-compliant contempt on one side and new kinds of justifications on the other for harming civilians.

Dr. Morrison: Michelle.

Ms. Strucke: Yeah, to add as well, I want to emphasize what Rick said about not creating a vastly insufficient parallel healthcare system. And even, you know, if things were considered like the use of hospital ships, those come with their own preparations and problems. They – you know, you need a port that can sustain it. There's a particular – there's a lot of very specific policy, I think, reasons and lead up why a hospital ship would not be, I think when I first hear it, the best policy solution. And that – I wanted to share, too, that on this idea of civilians, there’s been a lot of very toxic rhetoric coming out about the nature of civilians – Palestinian civilians. One thing I think that needs to be said is that a person’s political opinion has no bearing on whether they’re a civilian. A civilian can have any political opinion. That’s extremely important. And there – the suggestion that if people don’t evacuate that they are therefore presumed to not be a civilian is not – is not valid under international law. Civilians are civilians, and them not taking an action like evacuating doesn’t take that protection away from them.

And then one more point to share, too, is that on the situation of access and humanitarian organizations, I think one great need that has not gotten attention is the idea that the humanitarian organizations that are operating deserve to be able to have a process so that they can share where they are with the parties to the conflict so that they don’t get targeted, so that they know that they’re protected objects – that their clinics or their hospitals or places they’re operating, there’s a thing called a deconfliction list that’s very important. And that deconfliction, you know, I think what I – from what I’ve heard from operational humanitarian organizations is that they do not feel that those lists are being respected, so they don’t – they don’t feel safe. And the evidence is showing that they are not safe, considering how many aid workers have died. They also are subject, when they’re trying to bring in critical medical supplies, to restrictions at the border on the types of things that can be brought in. Basically, if something could be used for two purposes, a military purpose and a humanitarian or medical purpose, it’s being restricted. That list includes things like oxygen concentrators that are extremely important in a hospital setting that are restricted.

So I wanted to share those because the – both the nature of civilian objects is absolutely essential and the – you know, broadening that notion, as Len was saying, into harm more broadly means that it’s not just an individual decision where a military actor – Israel, IDF – is, you know, looking at whether a person – a particular entity or object can be targeted; it’s also the kind of cumulative effect of all of those individual decisions which can decimate an entire system. So I think there’s a number of levels that the idea of protecting civilians; understanding harm that’s being done to a broader civilian population; and then, as we are starting to get into and hope to have in future conversations, what are the longer-term impacts on this system that needs to – as Rick was saying, it needs to survive into the future so that there is a future. These are all important issues that I wanted to raise.

Dr. Morrison: Thank you.

Rick, back to you.

Dr. Brennan: Yeah. Thanks, Stephen.

And you know, I concur with what Len said, again. And you know, of course, WHO condemns militarization of any health facility. We haven’t seen conclusive evidence that this has happened, but if it is happening, you know, we condemn that.

I can say that a number of the facilities that have – well, at least the two facilities that have been accused of being militarized, we have staff on the ground and they can confirm that they have definitely been fulfilling their medical and lifesaving, you know, functions. Shifa Hospital, I – there’s been a lot of interest in Shifa Hospital, where there are claims that there are Hamas command posts in a bunker underneath the hospital. It is the largest facility in Gaza. It’s been providing tremendous medical service to the population for many years. I visited Shifa Hospital. Anecdotally, I can say that I’ve never seen any evidence of militarization. But nonetheless, it’s been – you know, it’s had a bed occupancy rate of almost 200 percent in recent weeks, meaning there’s two patients for every bed. And the doctors and nurses, again, lots of testimonials, lots of videos showing what tremendous work they’ve done under incredibly difficult circumstances.

That hospital and other hospitals in the north now have just been squeezed unbelievably. There’s no fuel, very little fuel left, very little supplies. We’ve got very little access. Those hospitals are progressively being emptied except for the critical patients. Right now, we – the latest information we have is there’s 650 to 700 patients left in Shifa. We are looking at options to do a major evacuation of the 36, 37 – (inaudible) – that have been in incubators. Our options are very, very limited at the moment. We’ve been in touch today through our country office. The Palestinian Red Crescent is not in the position to move those babies to the border where the Egyptian government will be willing to take them. And there are other – there are at least 27 critical cases in the hospital as well. And again, we don’t have fuel. We don’t have the vehicles. We don’t have the equipment and supplies to bring those patients down to the border. So ad hoc options are being looked at at the moment, but it’s been difficult over the last 24, 36 hours to put together a plan to evacuate particularly the most seriously ill in that hospital, which has been getting a lot of attention. A lot of the less severely ill, less severely wounded are finding their own ways to the south. But that would bring its own complications, of course, for those patients, particularly those who have been unstable or have serious injuries.

So it’s a terrible, terrible situation. I don’t think any of us have been faced with a context quite like this in our careers. We do believe the humanitarian situation will get worse before it gets better. And we are reassessing and adapting our strategy every couple of days based on the context. We need a ceasefire. The people of Gaza need a ceasefire. They’ve suffered too much. People in Israel have suffered too much. Hearts have become hardened on both sides. We need a return to an old-fashioned humanity.

Dr. Morrison: Thank you, Rick.

I want to turn, for the time that remains, to – I want to turn to the question of policy, and I’ll explain a bit in a moment what I mean by that. Netanyahu gave an interview – head of state gave for Israel gave an interview, an extended interview, yesterday on one of the American Sunday public-affairs shows and was very defiant – very defiant in terms of we are not going to deviate from our military objectives, which is to destroy the military capacity and the governing capacity of Hamas, which I take to mean that full speed ahead in the urban combat campaign in the north. And as you suggest, there’s a southern strategy also in the works; exactly what that will look like, I can’t say. But we are entering – we are entering a new phase of this war, and there seems to be full commitment on the Israeli side to pursue that even in the face of the calls and the pressures and the like.

And I want to, then, in that context, ask each of you a question around the policy environment. For Michelle and for Len, I’d like to hear your thoughts on how do you characterize current U.S. policy, and how do you ratchet up pressure, and what are you asking for. In the case of Rick, I’d like you to talk a bit about what’s happening in U.S. fora, but also what’s happened in Paris. There was a convening, a $1.2 billion plan put forward. President Macron has come out and openly sided now with the call for a ceasefire. Are there shifts of policy that you observe that are important for us to take into account at this moment in time?

So, Michelle and Len. Michelle, if you could lead off, say a few words about how you understand and characterize U.S. policy. And what more are you looking for? And then Len can add his thoughts.

Ms. Strucke: At the moment, the way – you know, the way I would characterize the way that the U.S. is looking at, you know, its bedrock alliance with Israel is one that I personally think of as, using – borrowing the word “toxic empathy,” it’s basically, you know, such a deeply-rooted, you know, important empathy that I think all of us recognize, but one that is maybe so empathetic that it’s allowing our partner to exercise conduct which is hurting them – hurting their own strategic interests, hurting the future of peace prospects for their country – and is hurting the United States. And so some constraint, I think, would be an understatement in terms of what needs to happen.

The U.S. at the moment is certainly – we see the secretary of state recently coming out and saying that too many Palestinian civilians have died. We see the rhetoric changing slightly. But it is important to realize that the U.S. is essentially announcing what they’ve viewing as, essentially, Israeli concessions on the humanitarian side to allow for greater humanitarian access, when those are things that Israel should be doing in the first place. If you, you know, stripped out the name Palestine-Israel from this conversation and you applied it to any other conflict, you would see the U.S. saying that any party in a conflict that is disproportionately killing civilians, indiscriminately targeting people, is committing, you know, atrocities, these are things that would – the U.S. would say, discredits them on the world stage. And I think it’s really important that, obviously, this context – this has a deep history and is sensitive for so many people and personal for so many people, up to an including our president – the president of the United States. That does not mean that anything goes.

So for U.S. policy, I certainly – as a humanitarian myself – understand, you know, the calls for a ceasefire to give an end to the fighting. And that is the only solution that will really relieve human suffering. And many of it is damage that cannot be remediated. But, given the stance that the U.S. president has taken on a ceasefire, other options that are much longer than a pause of a few hours, I think, are critical to work on negotiating. It’s a huge shame that in the practice of – you know, of the parties right now, we’re seeing a – basically human lives being used as bargaining chips. That, you know, that is what is being negotiated. A humanitarian pause or time is being negotiated in order to receive back hostages.

But the U.S. should be pushing for this unhindered access to those in need for much longer pauses, or stoppages, or cessation of hostilities as they have in other conflicts, and have expertise in doing, in order to allow people to get out of harm’s way. And as we mentioned, nowhere is safe. So looking at solutions to help and alleviate the places that civilians can go is essential. And being able to try to extract guarantees about a return. A lot of things happening in this conversation, people are not talking about the duty that Israel has to allow people to return to their homes. And that, I think, is really important because for people to be able to evacuate, they need to know that they will not essentially be giving up their claim to the place that they call home. And that’s a very powerful thing.

Respect for IHL, obviously, I think is critical. And the U.S. should be putting more – much, much, much more money into humanitarian assistance. And, you know, calling out the red lines for U.S. partners that are putting themselves into harm’s way in this conflict in order to deliver aid. So those are just – those are a few things I think need to happen.

Dr. Morrison: Thank you. Len – we’re going to run a few minutes over the hour, if that’s OK. And I’m going to ask Len to speak, and then Rick, and then we’ll do a lightning round of closing comments. But Len, over to you on this question of U.S. policy.

Mr. Rubenstein: From the start, the Biden administration has announced its support for Israel, vigorous support, military support, weapons support. At the same time, from the beginning, it urged Israel to comply with international humanitarian law. And over the last five weeks, it has become increasingly vocal – not only privately, but publicly – in demanding that, in in calling for protection of civilians, and calling out that too many civilians have died, to demand that Israel not occupy Gaza. And it’s also working, we know, to get the hostages released.

But that pressure does not seem to be working. And there has to be a much greater source of pressure. And one thing the United States government has never done is to make demands of Israel through the U.N. Security Council, which basically says the entire international community finds what you’re doing, your conduct in this war, unacceptable. And it’s a very big bridge to cross for the Biden administration. But I think it’s time to do that.

Dr. Morrison: Thank you. Rick. Your thoughts, Rick?

Dr. Brennan: Yeah. I mean, I guess, what really upsets many humanitarians is when we hear Israeli and American government officials say a ceasefire only helps Hamas. The ceasefire helps innocent women, and children, and men survive. And so a ceasefire is now viewed as the way forward. We don’t believe that there is a military solution to the problems that beset the occupied Palestinian territory.

You asked about policy orientations for the U.N. I think it’s very clear, I mean, the asks that I mentioned before around the ceasefire, the opening of humanitarian access, the unconditional release of hostages, the respect for international humanitarian law, and, of course, you know, protection of health facilities and other civilian infrastructure. I think the other thinking right now – you’ll hear this articulated more, I think, over the coming days to weeks, other grave concerns we have regarding a dependence on safe zones.

The design of the safe zones, as we understand it, or the safe zone, as has been described, has incredibly serious considerations for the provision of humanitarian assistance and protection. So the plans we understand right now give us cause for grave concerns. And we need to be providing assistance to people where they are. We can’t continue to force people to an area where we want them, where a military objective – that serves a military and political objective.

The final point I’d like to make is U.N. agencies -- we’re incredibly frustrated about feeling that we’re being instrumentalized towards – in support of those types of objectives, the political and military objectives, because increasingly our options to operate are being constrained. And we can’t operate in the north. You know, there’s a smaller and smaller geographic area where we may be forced to move. And we are being asked consistently to bring in aid to an area that’s being identified by the Israelis, and with support of the American government.

You know, a senior American officials said to me the other – I said, you know, we’re very concerned about the pull factor. You know, if we set up aid in a – in a given zone, and, you know, and deny it in another zone, it’s a pull factor, you know, dragging people away from their homes and where they want to be. And that official said, oh, the pull factor is desirable in this instance. We have grave concerns about that, from the history of – (inaudible) – of humanitarian action.

Dr. Morrison: Thank you, Rick.

This has been a pretty dark conversation, and which is fitting. And these topics are, themselves, traumatizing, I think. And I think Michelle said it very well, that in the current era of cellphones, and social media, and instant transmission, we’re seeing things that earlier would have been hidden or delayed. And, I think we brought across quite well in the course of this conversation just how exceptionally difficult and catastrophic this situation has become. And that what lies ahead is dangerous and could be considerably worse as this war unfolds.

I want to thank all of you. I want to ask you to each say just a short closing statement. And to the degree you can, tell us what gives you a little bit of hope in this situation. That would be a good way, I think, to conclude what has been a very difficult hour of conversation. I’m going to start with you, Len, Michelle, and then, Rick, you’re going to get the last word.

Mr. Rubenstein: Last week in The New Yorker, David Remnick, the editor, wrote a piece saying, hope seems far, far away. But we just have to keep working toward protection of the civilians, resolution of this conflict, and a commitment in the longer run – and we haven’t talked about this today – how there’s no military solution to this conflict. Everything about the conflict has to be resolved politically. There has to be a return to discussion of two states. There has to be protection of the human rights of everyone in the region. And we just have to work toward that, as well as dealing with the catastrophe today.

Dr. Morrison: Thank you, Len. Michelle.

Ms. Strucke: For me, every day that no solutions are reached for humanitarian access is a decision that policymakers are making not to reach that solution. We see, as minutes go by and we’re having this conversation, people are dying right now. So for me, the urgency cannot be overstated and the courage that is needed by government officials to be able to make decisions that they’ve maybe never made before on this – in this crisis, I think that is what is called for right now, are political leaders that are – that have moral courage and that can call out the toxic rhetoric about Palestinians, about civilians, about the conduct of the war. That is – that is critical.

What gives me hope? I find hope in the resilience of Palestinians that have already suffered so much, and of all of the people in Israel that themselves write about in Haaretz every day, protest, and want peace as well. I see some hope in that. And I see hope in my humanitarian colleagues who are issuing courageous statements that – going outside of the conduct that they usually have to sign letters, to make statements, and to call out when these horrific lines are being crossed that are – that are hurting people. There’s not a lot of hope here. But I think that we cannot give up hope, because that would mean that we are accepting that the decisions that are happening now are inevitable. And they certainly are not.

Dr. Morrison: Thank you, Michelle.

Rick, you get the closing word here today.

Dr. Brennan: Yeah. Well, always to – always important to end on a word of hope. So thank you for that opportunity. And what gives me hope? I don’t know, to be perfectly honest, just the human spirit. I mean, with – you know, I’ve been working in this field for over 30 years. And wherever you go, you find people who just won’t give up. There’s something within our human nature that drives us forward. You know, the mothers who care for their kids, fathers caring for their families, community leaders going the extra mile for their communities. You just can’t snuff that out. No conflict, no darkness, no negativity will ever snuff that out.

And so we have to identify that, in looking at these individuals with whom we work. We need to nurture. We need to support them. We need to give them the space and the resources to help themselves and their families, and I’ll do it. So, in spirit, it’s always there.

Dr. Morrison: Thank you, Rick.

I want to thank Len, Michelle, and Rick for the time that you’ve provided us today, and for the commitments – the longevity of each of your commitments in this area, which are just remarkable. And again, to commend WHO, and other U.N. colleagues, and other courageous NGOs that are working day-in and day-out, under extreme dangers in this period. It’s rather inspiring and remarkable, the perseverance, the stamina, and the courage that we’re seeing in this period.

We intend for this series to be periodic over the course of this crisis. So stay tuned. And we will reconvene fairly soon around a related set of topics to those that we covered today. And a special thanks to the production team here at CSIS and to my colleagues in the Global Health Policy Center and The Humanitarian Agenda, who contributed to making today possible. Thank you.

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