Gaza: The Human Toll—Episode 2

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This transcript is from a CSIS event hosted on December 1, 2023. Watch the full video here.

J. Stephen Morrison: Good morning, good afternoon, good evening, and welcome to the second episode of the CSIS broadcast series “Gaza: The Human Toll.” It’s a product of the CSIS Bipartisan Alliance for Global Health Security in co-sponsorship with CSIS’s Humanitarian Agenda and its Middle East Program. I’m J. Stephen Morrison, senior vice president here at CSIS, where I direct the Global Health Policy Center.

This is a very somber morning or a somber day: the return to war in Gaza after a seven-day pause for release of hostages and detainees and prisoners and increased flow of health and humanitarian goods. We’ll hear more about that in a moment.

We’re very fortunate to have with us today, Tom White, director of UNRWA Affairs, Gaza, coming in from Rafah in southern Gaza; and Rick Brennan, regional emergency director, WHO Eastern Mediterranean Regional Office, coming in from Cairo. UNRWA and WHO, as we’ll hear, deserve special praise for the courage and perseverance they’ve shown in these last eight weeks – eight, nine weeks amid extraordinary adversity and threat.

We’re very fortunate also to be joined here today by my friends and colleagues Michelle Strucke, director of the CSIS Humanitarian Agenda, recently departed DOD where she had responsibilities in some of these areas that we’re talking about today in terms of emergency humanitarian and health response; and Jon Alterman, senior vice president and director of the CSIS Middle East Program.

Just a quick reminder to our audience of the chronology. Hamas carried out a massacre October 7th of 1,200 Israelis and took 240 hostages; 5,431 Israelis were injured in that siege. The Israeli response was to impose a siege on and blockade upon fuel, electricity, water, and medicines. A 49-day aerial siege began, which involved very heavy weapons used against dense civilian areas, attacking 15,000 sites. A 30-day ground war began, started in October – October 27th. We’ve just completed the seven-day pause that began on November 24th.

We’ve seen recorded – and we’ll hear more about this – a ghastly humanitarian and health crisis in Gaza: reportedly, 14,800 killed, 36,000 gravely injured, 75 percent of those populations women and children; 6,800 reportedly missing; 1.7 million of Gaza’s 2.3 million civilians displaced, 70 percent, the majority – vast majority moving from the north to the south, doubling the density in that zone; 4,600 housing units destroyed, 234,000 units partially damaged, over 60 percent of housing units destroyed or damaged; in northern Gaza, in Gaza City and north Gaza, only two of 24 hospitals operational. Across Gaza, 26 hospitals and 55 health-care centers are out of service. Hospitals, as we’ve seen with the controversy surrounding Al-Shifa, have become a centerpiece of the debate over this war and the conduct of this war, and whether these health facilities are deserving of protection or not, or whether they are somehow compromised and complicit in this war.

The health status of the Gazan population is deteriorating. We’ll hear more about that. The cumulative impacts of malnutrition, lack of clean water, displacement, lack of adequate housing, the onset of winter, lack of health services, 1 million crowded into the south, that accumulating crisis is an infectious disease and health crisis. We’re seeing rapidly-rising respiratory and diarrheal disease, great fear of cholera, and likely rising mortality rates. These have not been slowed, I don’t expect, much by the seven-day pause.

We’ll hear a lot today about the new phase of the war that has just begun. Will we see safe zones? Will there be deconfliction? Will field hospitals surface as a – as a big component? Will the humanitarian channel cross-border be segregated from the negotiations over hostages and the like?

The United States has played a vocal role in calling for a different conduct of war. Whether that’s effective or not is a big question.

The humanitarian agencies themselves – and that includes UNRWA, WHO, the International Committee of the Red Cross, MSF, and others – themselves have been subjected to unprecedented levels of threats, misinformation, and attacks, and there’s questions around their ability to operate in this environment. UNRWA has reportedly lost 108 of its staff.

All of these humanitarian options that we’re talking about are, of course, tied to the broader environment of the resolution of the war and the resolution of the governing and future status of Gaza and of the Palestinian population there.

I’m going to turn momentarily to hear from Tom White, followed by Rick Brennan, to ask them to give us an update on where we are in the – as they see things unfolding. What was the outcomes of this last pause? And what do they foresee unfolding in front of them now?

I want to first – and then we will turn to hear from – hear from Michelle and Jon, and have a conversation among us that will carry forward to our conclusion at a quarter past the hour.

I want to offer special thanks to my colleague Sophia Hirshfield, who’s worked really assiduously to pull all the pieces together; and from the production staff, Dwayne Gladden and Qi Yu and Alex Brunner; and Alex Kisling from our communications staff.

So, Tom, I want to ask you to kick things off for us please, eight to 10 minutes of remarks. And then – and then we’ll turn to Rick. Thank you so much. I know this has been a(n) extraordinary day for you. We’re very honored that you could find any time to be with us. Thank you.

Thomas White: Well, thank you very much for the opportunity to join and a good opportunity to share with – share with you what’s happening here on the ground.

I thought I might just open my remarks by talking about what UNRWA normally does in Gaza. You know, and UNRWA, obviously, has a mandate to look after refugees. In Gaza, that’s well over half the population; pushing 70 percent of the population are refugees. Ordinarily, we are running schools for 300,000 children, primary health care for 1.5 million people. But also, because of the – you know, the 16-year-old blockade of Gaza and the impact that had on the economy, we were already providing food aid to 1.2 million people, and that was providing 50 percent of their calorific needs. We also had a partnership with World Food Programme, who was providing food vouchers for another 300,000 non-refugees. So there was a high level of aid dependency prior to the conflict, and that’s what we were responding to prior to the 7th of October.

We always had standing plans to be able to respond in the event of a war. Just to give you a sense, ordinarily we had plans that we could convert some schools into displacement centers to host 150,000 people with all of the supplies on the ground to support them over a 21-day period. Of course, we, along with all of the organizations in Gaza, have been totally overwhelmed by the events since the 7th of October.

Some personal reflections. I’ve been doing this for a few years, and I have never seen the level of death, destruction, and displacement in such a short period of time as I’ve seen in Gaza over the last month and a half. It’s taken an enormous toll on everybody in the community. For UNRWA alone, it’s now 108; another staff member died overnight of wounds received earlier in the war, so now 109 UNRWA staff have lost their lives. But this is really reflective of a community where all of Gaza is grieving. Everybody has lost family members or multiple family members, colleagues, and friends.

The level of destruction, particularly in the north, is quite devastating in areas. I was up in the north about three days ago and there are whole neighborhoods that will have to be rebuilt. So it’s a scene of total devastation up there.

And then there’s this issue of displacement. And so it’s these three things: the level of death, destruction, and displacement. So, you know, well over a million people have been displaced during the course of the – of the war. For UNRWA alone in the south, you know, we’re running 99 shelters, which are effectively schools and a couple of other facilities, hosting to date 958,000 people in those shelters.

In terms of what we have been dealing with in the humanitarian situation, there are a number of compounding factors. There is a problem with food insecurity. There is just not enough food. If you have got cash and you go into the market, there is very little food left on the market now. Certainly, in supermarkets and stores you cannot buy foodstuffs. It’s placing an enormous demand upon the international community, and particularly UNRWA. We’re in the process now of distributing wheat flour to over 2 million people in Gaza.

You know, a large proportion of the population are then living in these overcrowded shelters. Now, 99 of our schools; there are about 88 Palestinian Authority schools in the south. People are living in warehouses. They’re living in empty shops. Pardon me. They’re living in empty shops. And increasingly, particularly in the last couple of weeks as we saw the second wave of people come from the north, people are living out in the open, and they’re making – building tents and temporary lean-tos throughout Khan Younis and Rafah. These shelters that we’re running, to give you a sense, our emergency plans were always that we could host 1,500 people in a school that normally had a thousand students. Our average carrying capacity in those shelters now is well over 6,000 people. This is putting enormous strains on our ability to serve that population. You know, hundreds of people per toilet. I think it’s 700 people per wash facility.

Our ability to get domestic water to these people is now down – is somewhere between two to four liters a day. In terms of drinking water, people are surviving on about two liters. And the sanitation in these shelters is now the major concern. And I’m sure Rick will be able to talk to some of the infectious diseases, but with our colleagues from WHO, you know, we have been recording rising rates of watery diarrhea. Every time I go to a shelter, people are now lifting up their sleeves to show the skin diseases. And in the last few days, you know, we have recorded the first cases of hepatitis A in one of the shelters.

More broadly also – because this is not just about people living in shelters; it’s also people who are hosted by the communities of Khan Younis and Rafah – the infrastructure of the south is not designed to support this many people. It was always the least-populated part of Gaza, and it is now totally overwhelmed in terms of water infrastructure, waste infrastructure. So that’s putting enormous demands upon the situation.

I’ll finish off with a couple of comments on a few of the key dynamics. One thing is very clear: Aid is being politicized. You know, we have been working for about 15 or 16 years in an environment where access to food, water, jobs, health care was being manipulated by Israel to try and, you know, affect the dynamics within Gaza. Certainly now since the war that is very much the case.

One key commodity is fuel. We are very clear – very clear – that we need at minimum, just for the basic humanitarian services, 120,000 liters a day. We were existing on 60(,000), and I can talk to you about what we were not doing at 60,000 liters. It went up to 120(,000) during the hostage release. As of this morning, we were informed by the Israelis that they will now only allow 60,000 liters in. Not only that, but we’ve been told that no trucks will enter Gaza.

You will have seen a lot of reporting about the aid flows into Gaza. It is well below what we require to sustain a population now of over 2 million people.

A couple of final points. You know, we have been able to access the population in the north during the humanitarian pause. Really important to get up to the north. It’s a relatively small, you know, proportion of the population now, but it is very difficult for us to get access to the north. Essentially, we require on coordinating movements through an Israeli-occupied zone north of Wadi Gaza. And then, once we are in the city, it’s having to navigate through the city now with a conflict ongoing, navigating between, obviously, militants and also the Israelis who are, you know, undertaking operations in the north. So very, very difficult, but important we don’t forget the population in the north.

My final point is that there are – has been lots of rhetoric about once the operation in the north is finished that it will come south. The ceasefire was over, you know, by about seven a.m. this morning, or the humanitarian pause was over by about seven a.m. this morning. Not only did we start seeing airstrikes coming to Rafah – in fact, we’ve had three around the health clinic I’m working out of right now – we also started to see the pamphlets being dropped to communities who live east of Salah al-Din Road, the main north-south road. And so there is a very real threat of further displacement if and when the Israelis undertake a ground operation either in the three southern governorates of Gaza. All indications are that it may be targeted on Khan Younis, and certainly the leaflets that have been dropped by the Israelis this morning are telling people to move to displacement centers in Rafah. I can tell you there are no spots left in Rafah. We’ve got people sleeping on the streets in Rafah. The ability to host people who have been displaced, we’ve been totally overwhelmed.

I suppose my final message is that, you know, another major offensive in a place like Khan Younis will cost a lot of lives. It will lead to further displacement and probably the full-blown collapse of Gaza.

Thank you.

Dr. Morrison: Thank you, Tom. That’s a very chilling and profound and very candid presentation. Thank you.

Over to Rick Brennan. Thank you.

Rick Brennan: Thank you. Thank you, Stephen.

And thank you, Tom. Thank you for that very clear and sobering description. I think it’s a situation that we’re all, you know, still trying to digest, really. You mentioned you’ve never seen anything like this in your many years. And I – you know, I was at a meeting with some other humanitarian colleagues just about a week-and-a-half ago, and I think we all felt the same in terms of the number of acute deaths, displacement, and level of destruction. This is unique in the careers of many seasoned humanitarians.

You know, it’s concerning today we’ve seen, you know, recommencement of the military operations. We did have a little bit of respite over the last week, and of course great news that a number of the hostages were released and detainees released. But we were always just going to be playing catchup during any humanitarian pause, and that was certainly the case. We estimate that the humanitarian effort requires around 500 trucks per day; on average, during that seven-day pause we got in around 220. So even during that period, if you do the math, we probably had a deficit of around 2,000 (ph) trucks during that period where we were supposed to be getting aid in.

I’d like to make three main points in the next few minutes.

Firstly, we have got to – the health sector must be protected from any further degradation that it’s suffered over the last few weeks. In fact, that degradation not only has to be halted, but it has to be reversed.

Secondly, we’ve got to accelerate our efforts to avert preventable deaths, including due to infectious diseases, cessation of treatment for chronic disease, emergency – (inaudible) – emergencies, potential deaths due to hypothermia and due to malnutrition – as Tom indicates, huge food deficit across Gaza.

And the third – the third point is we just have to find ways to urgently scale up the aid effort. Our options are rather limited, but I’d like to touch on a few of those.

So, on the first point, as you know, the health system has been massively degraded since the start of the war. Now, of the 36 hospitals across Gaza, 18 of them are functional but all of them are only partially functional. We’ve gone from 3,500 hospital beds down to around 1,500 available to the people of Gaza today, and we estimate that we need 5,000. Of course, you know, so we’ve seen this decline at a time when the health needs are really skyrocketing and the ability of the health system to respond has really been degraded.

In the north, we have three hospitals that can take inpatients right now.

Al-Ahli Hospital, which is the only one that’s being able to provide surgical services for the wounded, but it is an 80-bed facility.

We have Al Sahaba Hospital, which is the only maternity hospital in the north that’s functioning; and we expect, you know, between 160 and 180 women to deliver per day. It’s the only place in the north providing caesarian section and emergency obstetric care.

There’s another smaller private hospital with very, very modest inpatient capacities.

A couple of other hospitals have come on – back online to a degree.

Al-Shifa, the emergency department is seeing a limited number of patients, but there’s no inpatient capacity. And the dialysis unit has started to work again at a very reduced level.

Similarly, an Indonesian Hospital – and these – Al-Shifa and Indonesian were two of the big hospitals – go-to hospitals in the north – Indonesian Hospital has come back online, but only its dialysis services. And we have just been told this morning that the Israelis have indicated to the managers of Indonesian Hospital that it should close down.

In the south, we have three hospitals that are really bearing the brunt. We’ve got European Hospital, Al-Nasr Hospital, and Al-Aqsa Hospital. All of them are working at around two to three times capacity. All of them are hosting displaced people as well. And there’s about another five hospitals with very modest capacities.

In the – in the context of escalation – of escalation of the military operations right now, if any of those hospitals go out of function, we are in a very, very catastrophic situation. Those hospitals, they have to be protected, they have to be deconflicted, and their supply lines have to be assured throughout any military operation. We cannot afford any further degradation. In fact, as I mentioned, not only does this degradation have to be halted; it needs to be reversed.

So what are we doing about it as WHO with our partners?

Well, firstly, we’re trying to ensure the continuity of supplies to the hospitals that are functioning. We are trying to expand their capacities by bringing in more beds, tented facilities, twinning them with international emergency medical teams. But they’re only available at a very limited level.

We are looking for options to reactivate hospitals and clinics that have closed. And you know, as we’ve indicated, in Shifa and Indonesian, a little bit of activity back there, but we need to do that more.

We’re bringing in and strategically locating a limited number of field hospitals. But our international partners who manage field hospitals, they – there are a lot of constraints to them setting up: the security constraints, the supply chain constraints, the access to fuel constraints. So only a limited number of international partners have come in to set up field hospitals.

And then, fourthly, we’re also trying to put in a more predictable mechanism for medical evacuations to Egypt and to other countries.

But the situation is clearly desperate and it stands to get worse with the onset of the military hostilities again.

Secondly, we really have to accelerate our efforts to avert preventable deaths. Tom’s mentioned the horrific situation in the – in the collective centers. You know, the situation’s completely ripe for disease outbreaks. We’re seeing increased numbers of respiratory infections, diarrheal infections, you know, two to three times the historical levels at the same time of year in the last couple of years. You know, Tom mentioned the skin rashes. You’ve got no idea what it’s like to see people covered in scabies. It’s one of the most miserable conditions anyone could endure, and we’ve seen it in a lot of places. I understand scabies is spreading, as well as other skin conditions and head lice. Tom’s mentioned the cases of hepatitis A. We’ve seen over 1,100 cases of jaundice. We’re particularly concerned about hepatitis E, which is another waterborne disease, which amongst pregnant women can have a case-fatality ratio of 25 percent, meaning it could kill one in four.

So what do we have to do to avert disease outbreaks? We have to decongest those facilities, if at all possible. We’ve got to reduce the populations of those collective centers and find other options for settlements, and we’ve got to address those very concerning problems related to the water. The sanitation – you know, we’re hearing from a lot of people – open defecation. When you’ve got one toilet for a couple of hundred people, you know, particularly kids, they’re not going to go into those toilets, which are used by so many people, and they’re often unclean and so on, so people go to the bathroom, frankly, you know, in open areas. So that’s a huge problem.

We’ve got to ensure again the continuity of services for women who are pregnant, particularly those that are delivering, and ensure that the 15 percent of the 180-odd women who are going to be delivering each day who have complication get access to caesarian sections, blood transfusions, and so on. Again, there’s over 300,000 people across Gaza with chronic diseases such as diabetes, high blood pressure, cancer, and so on; there are a number of different approaches that we’re taking to address their concerns. But it’s been a struggle to get the insulin in there because of the lack of cold chain. A number of cancer patients have been evacuated to third countries, which is good news for them, but the vast majority are being left behind, and there are struggles still with our supply chain to meet their needs.

I think one of the big problems – and Tom’s mentioned it: Winter’s around the corner. By some estimates, there’s around 500,000 people who have completely inadequate shelter, exposure to those elements. A lot of the people who are displaced, they’ll tell you, they didn’t have time to pack up their winter clothes. They just don’t have the clothing, the materials, the blankets to protect them from the cold weather. It would be a crime if we start seeing deaths due to hypothermia in Gaza. Similarly, this huge food deficit – you know, increased rates of acute malnutrition are just around the corner. It’s a toxic mix, with disease outbreaks, particularly for kids and the elderly. So again, we’ve got approaches to all this. We’re working with UNRWA on strengthening the disease surveillance in the health centers and also in the collective centers, so we can pick up potential disease outbreaks early, make sure that we’ve got teams that can respond. It’s very difficult to diagnose a number of these diseases right now because we don’t have functioning labs, but we’re looking at bringing in diagnostic equipment, taking specimens out, and so on. We’ve got to make sure that we address the problems of malnutrition, both through food aid and identifying kids who may be accurately malnourished early, and making sure they get targeted support.

The third point is just around scaling up the aid effort. As I mentioned, you know, we are well, well, well short of where we need to be, and frankly there are problems on all sides. There are problems with the aid apparatus here in Egypt, there are problems at the border, there are problems on the other side, and there are problems at global level. So right now we’ve got an international appeal asking for around 1.2 billion (dollars). That’s only 28, 29 percent funded. WHO appeal for 110 million (dollars)? We’re only around, officially around 11 percent funded. We’ve got more money coming in the pipeline, but it’s still well under 50 percent. So we don’t have the flexible funds, the resources to provide the aid at the level that’s required.

On this side of the border, working with the Egyptians, who are really trying very, very hard, but there are still problems with prioritization of aid, particularly when I think the U.N. and the NGOs – we’re working well together, we’re working well on prioritization and coordination. But then, when bilaterals bring in aid that isn’t consistent with what the U.N. and NGOs consider as the priorities, and they, for political reasons, get their aid in ahead of us, you know, as a priority, that causes more problems, particularly on the other side, for people who have to sort and deliver aid that may not be exactly what they need. So we’ve got to fix that coordination problem.

At the border, the Israelis run a verification process at a place called Nitzana. That operation is not working at scale. We’re not getting enough trucks through that process. It’s only open eight to 10 hours a day. By some reports, it’s understaffed. We need that scaled up.

And then when you get inside Gaza, all the problems with distributions – the lack of fuel. As Tom’s indicated, now we’re going to even have less fuel than we anticipated. The telecommunications – being able to communicate with people on the ground about where the aid is needed and how we can best target the distributions, but the lack of telecommunications remains a big constraint.

Thirdly, the lack of an effective and reliable deconfliction process – that means contacting the Israelis, letting them know where the aid is needed, where we want to run the convoys to, and ensuring we get the security guarantees, the safe passage. It’s not working the way that it should. It’s not working as a formal deconfliction process that we’ve established in many other countries.

So all of these issues complicate the delivery of aid.

Perhaps, you know – let me just pause here and again repeat what WHO and our U.N. partners consistently call for. The only way that we’re going to be able to avert the further deterioration of this already catastrophic humanitarian situation is a sustained cease-fire. That is absolutely required. You know, we have to appeal to the best of our humanity on this and less about the political dimensions. Secondly, we want to see, of course, all those remaining hostages released, and while they are in detention they need access to medical care and appropriate care. That’s absolutely essential. Thirdly, we want unhindered access to those in need. And fourthly, we need to protect civilian infrastructure, including the hospitals. One point that I omitted to mention is: The reason we’re seeing this degradation of the health system, it’s because hospitals and clinics have been checked off from their supply lines, and it’s because of attacks on health care. We’ve had over 200 attacks on health care since the start of this crisis affecting 56 health facilities. Civilian infrastructure, hospitals, clinics, ambulances all have to be protected.

Stephen, thanks for the opportunity to join you again.

Dr. Morrison: Thank you, Rick. And thank you, Tom. I think, in combination, your two presentations are really quite invaluable, and these are facts and perspectives that those of us here in Washington and beyond who are trying to understand what is happening need to hear. And so thank you so much, both of you.

I’m going to turn to my colleagues Michelle and then Jon to offer some thoughts on what we’ve just heard and offer their own perspectives and whatever issues they wish to raise. And we’ll cycle back to both of you, Tom and Rick, after we’ve had a chance to hear from them.

So Michelle?

Michelle Strucke: Thank you so much.

And thank you so much to both of you for everything that you and your organizations are doing to, you know, risk your lives to provide aid to people in need. It’s incredibly humbling and devastating to watch.

One thing I wanted to reflect on after hearing from both of you is just, there’s been narrative, you know, in the media, on social media of kind of a “this is war; this is what war is like.” And I think that it’s worth noting that the reflections of dedicated humanitarians that have spent decades looking at these things in the field and conflicts all around the world are saying this is worse. This is not the way that war, you know, is typically conducted; it’s not the way that war typically plays out. The devastation, the scale of the number of children killed, the number – the percentages, as Rick pointed out in our last broadcast, of the civilians that have been killed in terms of women and children, the reverberating effects of civilian harm, so all of the health impacts that we just heard about that are affecting the population and will cause tens of thousands of more deaths, or at least thousands of more deaths, if not more, than we’re seeing now. These issues are not typical.

And I think it’s worth pointing out, too, that the idea of giving assistance as being some kind of bargaining chip – I also want to push back on that narrative. The U.S. has recently made it very clear that in the negotiations to continue the pauses the humanitarian assistance should not be a bargaining chip. That humanitarian assistance must be sustained, scaled up, and continued. And I think the early indications that we just heard this morning are that, you know, the number of – with trucks being stopped and the number of aid that is being brought in being reduced from the time of the pause, this is very worrying. These are things that under humanitarian law civilians must be protected, hospitals must be protected. And, you know, militaries around the world, including the U.S., take great precautions to do this. And it’s very important that this narrative doesn’t get lost in a kind of fog of war kind of narrative.

Another important element is that, in terms of access, unhindered humanitarian access is so important. I know that there’s a – you know, while it’s a very difficult situation to get aid in, when the U.S. is considering its policy and Israel is considering what it does next, allowing that access is absolutely critical. And then on the scaling up of aid, there’s a lot of options that are being discussed.

But one I think I’m interested to hear more from Rick and Tom about is regarding the desire to open up a second border crossing. Kerem Shalom, before this started, was the primary kind of way that trucks were going in. And the fact that it’s not open and was not open during the pause for that purpose is something that I think is worth discussing. It’s an important way to ensure that, you know, the Rafah crossing, obviously, was mainly meant for pedestrians and not really designed to be bringing in aid at scale. So those are important elements. I’m interested to hear their thoughts on opening that crossing.

Other areas. One other thing I wanted to highlight too was that when we see in this context the situation of civilians that are caught in the middle, that are – that are displaced, not just once but multiple times. There’s reports of people not just leaving one place because it’s not safe, but they’ve gone to four or five different places, as winter is coming. It’s really important to just humanize the people that are caught in the middle. I think the way our media consumption works it’s very easy to either be overwhelmed by the amount of data you see coming out or to get in a lane where you’re only getting – you know, certain kinds of information is being put in front of you, depending on your perspective.

So I think it’s really important to remember that despite, you know, algorithms that are causing people to only see certain narratives on social media, there’s a level of, what probably feels like to people caught in the middle, of cruelty that they’re experiencing when they are exposed to, you know, lack of clean water, not adequate water, open defecation, watching their children have to experience these things. That is, again, in the humanitarian sense the idea of remembering the integrity of the actual people on the other end of this is somehow I think being a bit lost in the narrative. So I just wanted to share those things. Definitely interested to discuss more – some of the more policy options around scaling up. But at the moment, those are just some initial reflections.

Dr. Morrison: Thank you, Michelle.

Jon Alterman, our colleague here at CSIS, has been writing a stream of extremely valuable analyses and offering commentary throughout this crisis. And we’ve become very reliant on that. He’s been particularly astute also in interpreting the changes in U.S. policy approaches and what those mean. And this is a big moment of concern around what is U.S. policy, what is the impact and the like. Jon, thank you so much for being with us. And thanks for all the great work that you’ve done.

Jon B. Alterman: Thank you, Steve. And thanks to Rick and Tom for all the work you did for your presentation. I mean, it strikes me very much – I’ve spoken to the Israeli embassy about this – you know, the feeling – and I’ve spoken to Israeli military officials. The feeling is what they are doing is necessary. And the human consequences are unanticipated, but the acts against health facilities and other things are a necessary part of the war effort. It seems to me that if the goal – a principal goal the war effort is to split combatants off from the civilians in which they live, the kinds of stories we’re hearing from Rick and Tom are not serving that goal.

They’re serving to isolate Israel in the international community. They’re creating tensions between Israel and the United States. I would be particularly interested – you know, yesterday I saw the clips that the Israelis had put together from the social media and body cameras connected to the massacre on October 7th. And one of the things that struck me as I looked at the Hamas fighters celebrating absolutely heinous things was just how much trauma they must have experienced to get them to that state of elation over such evil acts. And one question I’d be interested to hear from you is your sense of the trauma that this is causing, the sense of the trauma that it is layered upon because, of course, this is not the first Israeli confrontation with Gaza.

When I’ve spoken to Gazans, they’ve told me that in many cases living in Gaza you never actually meet a living Israeli. You see the planes flying overhead. They drop the bombs. But you never actually meet an Israeli. And it does seem to me that that all these things are coming together, that there is an unintended and undesirable impact for Israeli war aims that are coming from the humanitarian situation that not only we have seen, but as you powerfully described, we are going to see as a consequence of poor sanitation, lack of water, sustained lack of access to health facilities. I worry that even if we stay in the current course the humanitarian consequences are going to grow much more dire. And the Israelis are talking about many more months of this before they’re ready to end major combat operations.

The other thing, and Michelle talked about it a little bit, you talked about it a little bit as well, is the issue of logistics on the Egyptian side, getting things in, getting the border crossings open. I mean, I lived in Egypt, worked in Egypt for several years. Logistics are not always a strong point in Egypt. I heard that one of the initial things Egyptian military was trying to do was get rid of expired food and get credit – full credit for expired food getting into Gaza, rather than getting in things that are needed. And there is, of course, the issue of the Kerem Shalom crossing, but I think there are a broader set of issues of what is necessary in northeastern Sinai in terms of warehousing, inspection facilities, the kinds of things that nobody actually enjoys funding, because it’s not glamorous but is so important as a force multiplier to have a stream ready to get it in.

I guess my hope would be that from an American government perspective there’s a lot of sensitivity to having a stark improvement in humanitarian conditions for Gazans. Michelle knows this much better than I do from her experience at the Defense Department. When the U.S. is a combatant, it puts tremendous effort into the wellbeing of civilians in combat areas. And I think that if we can figure out ways for the international community to create a better logistics operation outside of Gaza.

I wonder if then there could be a much stronger U.S. diplomatic effort to get the Israelis to think differently about letting a lot of that aid in, and that it sort of becomes more of a one-two effort, with international effort on the – on the logistics, organization inspection – very legitimate concerns – and then the Israelis coming around to an American point of view that having kids with scabies and lice and cholera and all the other things that we have already started seeing and may be seeing a lot more of, is not going to advance Israeli war aims. And perhaps there’s a – there’s a way to do this better. And I’m just wondering what your perspectives are of what are the near-term needs to help get to that place.

Dr. Morrison: Thanks, Jon. Thanks, Michelle.

Let’s turn now back to Tom and followed by Rick. Tom, your thoughts.

Mr. White: Just a couple of reflections. Just to pick up on this last point, you know, the simplest solution is to enable commercial access to Gaza. Instead of us trying to work out how we bring food into Gaza, let’s just open up the food market, let businesses in Gaza replenish their inventories. That’s, of course, unless less food is a dual use item. And this is where it comes to the politics of it. You know, the simplest way to fix the food insecurity issue in Gaza is to allow food in. Lots of people have got the money to pay for the food, but there’s just nothing left to buy. So we would be advocating opening up commercial access to Gaza.

Now, interestingly enough, during the humanitarian pause the Israelis allowed in cooking gas. And initially they said to us, well, can the U.N. organize the cross-border operation and the distribution of cooking gas? Now, cooking gas in Gaza, LPG, is, you know, several layers of distribution networks ending up with a guy who sits on the – on the street corner, and I walk down with my 12-kilo bottle. And because for many people they can’t afford to fill a whole bottle, fill up a liter as they go. Of course, we cannot replicate that. And a humanitarian system is never designed to replicate the private sector. So I would be pushing for private sector access. And, of course, the logical place to do that, and that’s where it’s been, you know, managed for many, many years now, is Kerem Shalom.

I’d just like to echo the comment about multiple displacement. That’s certainly what we understand, and particularly people in the north. In the shelters that were operating in the north, we can see that people are moving to different shelters over the course of the days or weeks to avoid the fighting. So that’s definitely happening. So there is multiple displacement.

Final comment, just on the issue of trauma, psychology, and what have you. The actions of the young men on the 7th of October is not reflective of Gazans. Now, I’ve been living in Gaza for two and a half years. And that’s not my experience with the vast majority of Gazans. But what I did experience with the vast majority of Gazans is they talk about the issues of mental health like I’ve never experienced in any other context. And it’s the trauma of ongoing wars. It’s the trauma of, you know, massive levels of unemployment, the inability for young people to lead a normal productive life because they’re starved of opportunity.

In our schools, after the May 21 conflict, about 38 percent of our staff – sorry – of our students were exhibiting signs of trauma, acute trauma. And a lot of the symptoms are what you see in PTSD. Now, the psychologist who’s been following this group of kids through, because we did the assessment of over 30,000 kids when they entered grade one and she’s followed this cohort through, that – sorry, I’ve lost my train of thought here. You know, the sort of – sorry – the level of trauma for those kids affecting their psychological makeup, you know, issues in the household, behavioral issues, inability to learn – I mean, there is an enormous level of psychological trauma in Gaza before the conflict. And I think that it’s going to take decades to heal the mental scars of this war.

Dr. Morrison: Thank you. Over to you, Rick.

Dr. Brennan: Thank you. Thanks, Stephen. And I fully agree with what Tom said. You know, there’s a lot that could be said about the logistics operation in northern Sinai. And, you know, there are operations there that are that are very challenging. Probably most of the people that have tuned in are aware that it’s a militarized zone, northern Sinai. And there are reportedly presence of ISIS there. It’s perhaps one of the most militarized areas I’ve ever been to. Every kilometer or two there is a military installation that preceded – that’s been there for years, because of the presence of Islamist groups, and so on.

So even for us to get access to northern Sinai, a challenge for the international community. There’s a lot more that I can say about that, but time won’t permit. So we do need to do a lot better in strengthening that operation in northern Sinai. We do have constraints because of the security concerns of the Egyptians. But Tom is absolutely right, we absolutely need a second crossing. And humanitarian aid will never meet all the needs in Gaza. We need that – we need the private sector reenergized. We need those commercial lines opened again.

Perhaps just in response to what Michelle said about what’s – (inaudible)– you know, unfortunate to see all these civilian deaths and all this level of destruction and displacement, but this is war. And Tom kind of – sorry – Jon sort of followed up with a kind of related question. Well, you know, in his discussions with the military, the Israeli military, well, these humanitarian consequences are unintended, but they’re just the outcome of a necessary security operation.

Well, you know, we have rules of war. And, you know, when I hear – I’ve actually got – you know, I’ve got a friend or two who have said, well, this is war. This is just what happens in war. Well, for someone who’s been working in, visiting war zones for over 30 years, it’s, you know, almost crushing to hear people say that. Because what people don’t – you know, and I think it – I think it’s a reflection that comes out of – more out of ignorance than malintent. I know very good people who have this attitude.

They haven’t experienced what it means to be caught up in war. The fact that well-meaning civilians, you know, women, children, innocents are, you know, the ultimate main victims. And our rules of war that have been developed, we have rules of war. We have the Geneva Conventions to put constraints on the way that military activities are conducted to, as best as possible, avoid civilians and civilian infrastructure being caught up in crisis. There’s no such thing as all’s fair in love and war.

You know, we have codified laws, the international humanitarian laws. Even going back centuries, we have this concept of the warrior’s honor, that it’s not appropriate to go in and have a scorched-earth policy. That you don’t go and eliminate women, children, whole communities. So, you know, the reality of war is always ugly. And people who have that attitude of, well, this is war and this is just what happens, no. There are rules. There are – there’s conduct to way that that fighters and militaries should conduct themselves to minimize the impact on the civilian population.

And I – you know, as I think we discussed on the last panel, I would contend that there are elements of the conduct of this conflict that give great, you know, causes for concern. The fact that two-thirds of the deaths are amongst women and children, that’s not what we usually –that’s not usually the pattern we see. It’s not the pattern we’ve seen in the conflicts in Gaza in 2008 and 2014. That number was inverted.

Thirty-five percent of the deaths have been in southern Gaza. That’s where people have been told to go. But 35 percent of the deaths have been there. We’ve had the attacks on healthcare. We’ve had weapons used in high density areas that the experts are saying are unusual, are of a size and impact that are unusual – that are unusual to use in that type of context. So I do think there is – there are serious concerns with the way that this conflict has been conducted.

Perhaps just one final point. And, you know, Jon’s point about what kind of trauma have these, you know, militants been through to get them to act in that certain way. And, you know, Tom’s answered that extremely, extremely well. You know, the vast majority – we all know Gazans. We all know they’re hard workers. You know, I’ve got quite a few colleagues, you know, professionals – you know, proud professionals. You know, look at what they’ve done with their health care system before this conflict, in spite of being strangled from – you know, with the siege over the last years. Their health outcomes are very impressive, you know, prior to the conflict. They’re sort of middle range for this – for this part of the world, which is a pretty amazing outcome given the context in which they operate.

But I do remember, you know, about three decades ago around the Oslo Accords. I remember two of the main negotiators came out, one Israeli, one Palestinian. And the Israeli guy said, I finally understood what dignity meant to him. And he finally understood what security meant to me. And, you know, there are these different narratives going on about the tensions between the Palestinians and the Israelis. And I do think that a lot of it still circles around these two issues, that the Palestinians want – they want their dignity, they want their rights, they want to live in freedom. And the Israelis, they want to feel secure. And those two goals, those two desires, are in no way mutually exclusive. But unfortunately, I think we’ve got ourselves in a narrative sometimes to make people think that they are. Thanks again, Steve.

Dr. Morrison: Thank you, Rick and Tom. I’m going to say a few things, and then I want to turn back to Jon and Michelle for some additional comments.

One thing that’s come across recently is that when you talk to international NGOs and U.N. agencies and the like, many of them are beset by pretty profound internal strife between their workforces and their own leadership. That’s certainly something we’ve seen, to WFP and elsewhere. There’s also a sense that they are subject to disinformation campaigns in social media and elsewhere alleging that they are complicit with Hamas. And that this is a very dangerous sort of phenomenon, these allegations of complicity. And I think the confrontation and continued unresolved controversy around Al Shifa sort of brought much of this forward. And I wanted you to comment on that.

The second thing I wanted you to comment on is we saw some pretty impressive negotiations conducted, led by the Qataris, around the hostage/detainee/prisoner exchanges and the pause in the siege – temporary pause in the humanitarian siege. What does that perhaps tell us about what might be possible on the issues that we’re talking about here? I think Jon was hinting around that there are things – more could be done at a diplomatic level. We have seen some impressive diplomacy involving the U.S., the Israelis, the Qataris. Indirect discussions that pulled in Hamas and others. And maybe there’s a possibility of taking some lessons from that.

Jon, you had some thoughts?

Dr. Alterman: I just had a couple of questions. You know, one is just to extend Steve’s last point. I’m wondering what role you think the Gulf states might play more constructively. There’s a lot of interest in support in Saudi Arabia, the UAE. I got a sense that you had felt sometimes these states were able to get their aid in, in inappropriate ways. But I’m just wondering about your sense of the opportunities for Gulf diplomacy on the humanitarian side. And I think, obviously, there’s also some role for Gulf diplomacy on some of the governance and security issues further down the line at a different point.

The other thing is I’m, you know, very curious in Michelle’s experience in the U.S. government of just thinking very differently about care for civilian populations. And I don’t think we’ve heard a lot about it. It’s not something the U.S. advertises a lot. But I would be very interested, as my new colleague, to learn from her and to understand for somebody who was embedded in operations to help civilian populations, what is most jarring and what are the low-hanging fruit that, in her mind, the Israelis might be thinking about that would have the greatest impact?

Ms. Strucke: Well, I can take that a little bit. I think that it has been very jarring. It’s been jarring to hear about the kind of – not just the conflation. This is certainly the headline. But the conflation of any assistance to the population, be that electricity, be that fuel, be that water – basic clean water and access to clean water, cooking gas. These things being viewed as – with such disdain, and conflating it as all – the kind of narrative that it’s all being diverted, it will all be diverted, to Hamas. What I’ve heard from operational organizations is that they’re not seeing that play out. They’re not seeing this massive diversion playing out.

And when it comes to kind of the U.S. approach to civilian harm, the U.S. approach to the population, I experienced personally a lot more care given to these questions. A real horror from defense officials when I worked with them about the unintended loss of life that happened from U.S. military operations. It’s a real – it’s a trauma for the people that have done it. It’s a trauma for those that realize that the – that those were not the targets that they were intending. And just the devastation of knowing that this is permanent, this devastation is permanent. You can’t take back those lives.

And the U.S. government recently initiated some civilian harm reforms that were specifically aimed at ensuring that those who are military operators that are engaging in hostilities, they are able to have a bigger picture of civilian harm that isn’t just an incident-by-incident picture. You know, under humanitarian law every single time a civilian or any structure is being targeted, or a person is being targeted, that specific place has to be looked at to see what the proportional impact is on the civilians that that could be present. It’s not a generic kind of, well, we know that there are – Hamas is using people as human shields, which is heinous, and therefore we can do kind of indiscriminate attacks against all of these different places. It’s a unit-by-unit, you know, building-by-building, minute-by-minute calculation. And then that calculation regarding civilians has an impact on the wider civilian infrastructure. So there’s a collective impact and a systemic look.

So the U.S. recently initiated reforms, just specifically to widen that view of civilian harm from a unit-by-unit analysis to be more careful. So I think that the callousness that at least is being portrayed from statements that we see from a lot of Israeli officials is very jarring. And it’s something that doesn’t resonate with me as someone that worked with defense officials in the U.S., that took it so deeply seriously. So I think there’s room there, as you’re kind of implying, for the U.S. government to do a number of things. One, make sure that there’s integrity in the humanitarian aid that they’re providing, that it’s separate, that it’s seen as essential. It’s not a bargaining chip, as I said earlier.

But also, for the U.S. military to be playing a role of working with Israel as an ally to better explain the way they view the civilian population and, importantly for them and for their military objectives, the way that they’re looking at this in terms of the longer-term strategic effects that this could have. You know, they have military objectives, but they can’t operate in a kind of reactive manner. The strategy – for example, when the U.S. is calling out Russia for the way it’s conducting itself in Ukraine, that’s an example of a party that is largely – does not have legitimacy on the world stage because it’s hurting civilians in such a horrific way.

Basically, I’ve heard the point made over and over that it’s not strategic for Russia to conduct itself that way, and in the same way I think people have pointed to that conduct to say that, again, it could hurt them strategically.

So, obviously, as a humanitarian this is not the kind of topic that we typically weigh in on but to the extent to which these issues are important I think it brings – it does bring up questions about the U.S. role, how they’re talking to Israel as an essential critical ally and how they’re reflecting on 20 years of U.S. wars where there’s a lot of lessons that have been learned – painful lessons, lessons in people’s lives – that have been learned from experience that, you know, in relation to how the U.S. thinks about a civilian population.

Dr. Morrison: Thank you. We’re going to carry on if we can for a few more minutes. I’d like to come back to Rick and then Tom in response to these issues and then we’ll do a closing – a closing section for a few minutes.

Rick, would you like to say anything in response to what we’ve just heard? And then we’ll turn to Tom.

Dr. Brennan: I think Michelle has responded, you know, very well. I think that if – you know, we talk about the principles that should guide military conduct – proportionality, distinction, precaution – and, again, you know, we’re concerned that the conduct of this military operation has not been consistent with those principles, and I agree with Michelle. It think that does not help them strategically.

You can see – you know, as you’ve indicated there have been concerns expressed within, you know, the political parties within the U.S. divisions within the government, even concerns and divisions within some of the big humanitarian agencies, as you’ve indicated, Stephen, because people see this and, you know, the protection of civilians is – you know, is a foundational element of humanitarian law and we – you know, it hasn’t been adhered to sufficiently.

So, you know, I think the more pressure that can be put on the Israelis as they conduct their offensive the better and we have to say Hamas, you know, have shown disregard for the civilian population of Israel as well and, you know, I have friends who have been working with survivors of their assault and they need to be called out as well for their vicious attack and the atrocities that they have committed.

But so we all have responsibilities to conduct ourselves under – you know, under international humanitarian law when there is, you know, a military offensive undertaken. I couldn’t agree with Michelle’s comments any more.

Dr. Morrison: Thank you, Rick.

Over to you, Tom.

Mr. White: So I think Rick has really nailed the last question about the international humanitarian law so I might turn my attention to this issue of sort of internal strife within organizations and then organizations under attack.

To start with, certainly UNRWA has been under sustained attack for many years. I won’t go into all of the details of it but, you know, certainly the politics of this conflict means that, you know, UNRWA is continually defending the work that it does in the region.

It’s widely acknowledged by many countries both in the region and outside the region of the stabilizing role that UNRWA plays in the region. Despite that, constant political attacks. So that’s not new to us.

Secondly, in terms of internal strife, leading the UNRWA operation in Gaza we have 13,000 staff. You know, our ability to operate depends upon our staff. We’re a very people-centered organization. So it’s been – it has been a challenge in the last seven weeks in terms of working with a group of people who’ve lost family members, friends, colleagues.

A large majority of our workforce are now displaced. A large majority of our workforce not only are they coming to work but then at the end of the day they need to queue for bread or queue for water, many of them living in these collective centers.

So, you know, we’ve been – you know, there – I wouldn’t say there’s strife within the organization. What we’re doing is struggling to cope with the situation. Our staff remain exceptionally committed to their work. Whether they are doctors or nurses in a health clinic, schoolteachers who are now running collective shelters, they remain very committed to their work.

But the one thing that I’d say has been a big issue for many of them to deal with would be the sense that, you know, they put so much faith in the U.N. and international organizations and, you know, when they see UNRWA schools hit in airstrikes, when they see our operation starved of resources so they physically don’t have the aid to provide to their population, I think that’s really jarring for our staff.

You know, these are people who, you know, were committed to the ideals of the United Nations and on the ground every day they’re trying to reconcile their living and working circumstances with these ideals which, to be fair, seem to be trashed by certain parties to the conflict and other parts of the international community.

So that’s the biggest issue we have been dealing with staff. But, you know, here I’d also reflect on the community. So our chief of education who runs, you know, 294 schools, 300,000 kids, a workforce of 10,000 teachers, in UNRWA schools you get the normal curriculum but kids are also in – there’s education programs about tolerance, conflict resolution, human rights.

You know, we’re really trying to build young children in Gaza so they can think and act like global citizens, and Farid Abu Athra, our chief of education, was in one of the collective shelters and a young boy recognized him and ran up and said, Mr. Farid, what’s happened to the issues of conflict resolution, tolerance, human rights? Please explain to me what’s happening right now.

And I think that’s really reflective of a lot of the Palestinian community here who have put their faith in the, you know, multilateral institutions, international law that underpins their protection. But when you continually have collective centers in UNRWA schools with people killed under a U.N. flag it’s very tough for people to reconcile that here in Gaza.

Thank you.

Dr. Morrison: Thank you very much, Tom and Rick.

We’re getting towards the closing. There’s a couple of key points that I’m taking away from this. One is that this staggering humanitarian and health catastrophe in Gaza will continue to scale and we will – we should anticipate that and plan accordingly. We didn’t spend a lot of time talking about U.S. policy and U.S. leadership but certainly I think we need stronger leadership in this domain.

We’ve seen some positive steps but we need clarification of what the policy goals are and the ways in which U.S. is going to use its influence to achieve these protections and openings that we’ve talked about.

A third point is it seems to me that we do need – and this builds on one point that Jon had made that we do need a bigger conversation about the gaps. We need something that brings together high-level leadership, political leadership, to focus on the scale of lift required and the speed that’s needed, the capabilities and the speed of – and the scale needed and the types of protections and security that are going to be required in this situation and we can begin with looking at how to do that outside the boundaries of Gaza while also beginning a dialogue with the Israelis that has not been quite as open and multisectoral around how this could happen.

Final point, I want to just offer my thanks and the debt we all have to WHO and UNRWA for the courage and the perseverance and the commitment that they have shown and I want to thank my colleagues Michelle and Jon for their remarkable contributions to this debate.

The first episode Rick joined us and I sprung a question on him at the close as to, you know, give us something that can allow us to end this conversation with a bit of hope because this is such a sobering and overwhelmingly dark moment.

And so I’d like to ask Rick and Tom if there are some things that you can point us to as we close.

Thank you.

Dr. Alterman: And Rick is in a dark moment because it looks like there’s another power outage in Cairo.

Dr. Brennan: Indeed.

Dr. Morrison: So over to you, Rick, and then, Tom, you get the last word.

Dr. Brennan: Can you hear me, Stephen?

Dr. Morrison: Yes, can hear you.

Dr. Brennan: OK. Yeah. Sorry. I was having trouble with my mic.

What gives me hope? Well, you know, as I said, I think, the last time you asked me, Stephen, you know, the resilience of people, the human spirit, you can – you know, the way that our health workers, the way that the community workers are still striving to serve their communities under unimaginable conditions.

So the fact that there are people who are still well intended still delivering and serving their people day in and day out, and we see this across the globe in every crisis, and Tom and I have been around this game for a long, long time and we see it repeatedly. So that’s always inspiring and that’s always a source of hope.

I think there is a growing realization that the humanitarian catastrophe that is ongoing in Gaza needs a different approach that we – I think that the political process is moving far, far, far too slowly but I do see a couple of green shoots and I will hope against hope that we see more progress on that front.

Dr. Morrison: Thank you, Rick.

Tom?

Mr. White: Look, I’d echo Rick’s comments about the human spirit and the sense of service of people in these sorts of situations. Really remarkable. I certainly on a personal level, you know, in a few of the darker moments draw strength from knowing that, you know, I’m working with a really, really remarkable group of Palestinians who are serving their community. So I really echo Rick’s comments there.

What gives you hope is – and this is being, you know, driven by our senior national leadership in the organization right now – Tom, we need to get the education system going again. You know, Gazans above anything else value education. As refugees – multi-generational refugees – a man said to me very early when I started working in Gaza, I cannot give my children land, I cannot give my children a country, but I can give them education.

And so Gazans are a remarkably well educated group of people and what gives me hope is when there is an appetite to continue to educate the young people of Gaza because, you know, and this is one of the things that UNRWA is very committed to because that does help build a generation of people who can embrace a more peaceful and prosperous future.

So for me that – it’s education is the thing that gives me hope.

Dr. Morrison: Thank you both, and thanks to Michelle and Jon. We will be posting a transcript very soon from this show. The video is posted immediately. We will continue in this series on an episodic basis so stay tuned as to when we have our next broadcast of this series “Gaza: The Human Toll.”

Thanks to everyone who’s taken time out of their day to join us today in the audience and we adjourn. Thank you.

 (END.)