Gaza: The Human Toll—Episode 6

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This transcript is from a CSIS event hosted on February 7, 2024. Watch the full video here.

J. Stephen Morrison: Good morning, good afternoon, good evening. I’m J. Stephen Morrison. I’m senior vice president here at the Center for Strategic and International Studies, CSIS, a Washington, D.C.-based think tank, where I direct our work on global health. Today’s broadcast is the sixth episode of “Gaza: The Human Toll,” a CSIS series. It’s a product of the CSIS Bipartisan Alliance for Global Health Security, in cooperation with the CSIS Humanitarian Agenda and the CSIS Middle East Program. It’s an effort to track accurately and fairly the human and health crisis unfolding within Gaza, and to ponder what more the United States and others can do to alleviate the unspeakable suffering that we’re seeing in Gaza.

I wish to offer special thanks to my colleague Sophia Hirshfield, who’s worked very assiduously to pull all the parts together for this episode and those previous. I also wish to thank our gifted production staff, Alex Brunner and Dwayne Gladden in particular. I will be joined today by two and possibly three experts and friends.

Coming in remotely is our colleague Michelle Strucke, director of the CSIS Humanitarian Agenda, and director now of the CSIS Human Rights Project. Welcome, Michelle. Thank you so much for joining us. Until late in 2023, she served at the Department of Defense as a deputy assistant secretary for global partnerships.

With me here in the studio is a close friend, Leonard Rubenstein. Welcome, Len. The professor of practice in the Department of Epidemiology at the Johns Hopkins University Bloomberg School of Public Health. He’s a renowned expert on armed violence against the health sector during war. He’s the author of the landmark study “Perilous Medicine: The Struggle to Protect Health Care from the Violence of War,” published in 2021. He’s a nonresident fellow of the CSIS Global Health Policy Center. We published back in January, on January 12th, Len and I published a commentary on the CSIS site, entitled “Gaza’s Human Crisis Demands a Rethink.”

We’ll be joined momentarily, we’re hoping, by a third guest – or, we’re being joined right now by our third guest. Another friend from Chicago. We’re joined by Dr. Zaher Sahloul. He returned in late January from a medical mission to Gaza, where for two weeks he was providing medical services in hospitals and elsewhere in Khan Younis, in Rafah, in southern half of Gaza. He’s a medical doctor, a critical care specialist at Advocate Christ Medical Center in St. Anthony’s Hospital in Chicago. He’s an associate professor in clinical medicine at the University of Illinois. He founded and is a leader within the global NGO MedGlobal, that provides critical services to many war settings. And was also a founder and leader of the Syrian American Medical Society years back, when we came to know one another very well.

Since we last met on Monday, January 22nd, the last episode, a lot’s transpired that we’ll touch on today. On January 26th, the International Court of Justice issued its judgment on the charges that had come forward from South Africa on genocide. It issued six provisional measures. We won’t go into all the details of those, but it did instruct Israel to take additional steps to meet the urgent humanitarian needs of Palestinians in Gaza and is taking measures to hold Israel to account for that.

Around the same time, Israel allegations surfaced that 12 UNRWA staff – the U.N. Relief and Works Agency for Palestinian Refugees, founded in 1949 – the 12 staff had participated in the October 7th massacre of Israeli civilians. UNRWA dismissed 10 of those 12. Two had passed already. Up to 18 donors, as of today, have suspended their contributions, including the very heavy supporters, the United States and Germany, in particular. Subsequent to that time, an Israeli dossier has surfaced alleging that 10 percent of UNRWA’s 13,000 employees are affiliated with Hamas, including 200 militants.

These actions have resulted in an existential crisis for UNRWA itself. We’ll talk a bit about that. It’s also put into great peril its ability to continue its mission. And its mission of providing humanitarian relief and shelter for over a million-and-a-half displaced, education, medical care to the majority of those in Palestine is fundamental to simply holding things together in such a perilous situation today. So it’s – this crisis, it’s difficult to underestimate the gravity of what this means for Palestinian civilians and what it means for the continued integrity and legitimacy and functionality of UNRWA itself. There’s an international independent investigation underway. There’s other investigations underway. There’s a certain urgency in resolving this matter and restoring funding so that we don’t see the bottom fall out of what is already a very, very fragile situation.

Obviously, the war continues. We’ll hear more about the war, particularly as it’s been concentrated in the south; the threat of action against Rafah, where you have over a million of the 2.2 million Palestinians crowded in and around Rafah. That is a question on everyone’s mind right now. There’s been actions to try and return to the north. There’s an estimated 200,000 Gazans still in the north. That area has been largely closed off and partitioned for the time being.

Obviously also, in the bigger picture, there have been intense and resumed negotiations at seeking to find a way forward in terms of some combination of a phased ceasefire, exchange of hostages, detainees and prisoners, and the opening, on an urgent basis, of humanitarian corridors and the like.

All of these actions, of course, occur against a backdrop of also needing to demand more of Hamas itself in terms of ceasing diversion of aid, ceasing use of civilians as human shields, and release of hostages.

What we’re going to do today, over the course of this hour, I’ve asked our three guests to come prepared with some opening remarks. We’re going to move through the three of them. We’re going to start with Zaher Sahloul and hear about his time in Gaza that just recently concluded and what were the major impressions that came from that. We’ll then turn to Michelle Strucke for some of her observations, and then we’ll hear from Len. Len has been tracking very closely the developments surrounding the hospitals as well as the broader health conditions within Gaza.

So thank you all for joining us. Thanks to my three – our three guests and close friends for being with us today. This is a terribly important effort, I believe, and the timing is quite important.

Zaher, welcome. I’m going to turn things over to you and you can kick things off with six to eight minutes of remarks. Thank you.

Zaher Sahloul: Good morning. Thank you for having me. And I’m really happy to connect with my friends, with you, Steve, with Leon and with Michelle.

I just recently came back from Gaza. I’ve been in medical mission with MedGlobal with a team of five physicians from January 9th to January 24th. So I’m still processing, actually, what I have witnessed. And as you know, Steve, I’ve been in many other disaster areas, including Syria, Yemen and Ukraine. I’ve been in Gaza myself three times before this war. And the situation is beyond description.

Everyone knows now that this is probably the worst humanitarian crisis in our lifetime, not only because of the scale of the crisis itself that is affecting 2.2 million people, the number of injured people, more than 63,000 or 65,000. Half of them have moderate to severe injuries. Many of them are awaiting evacuation, about 6,200 awaiting evacuation. Only 10 percent of them have been evacuated. The rest are – Gaza doesn’t have the infrastructure to provide surgeries for them. That means they will linger in the ICUs or the hospitals until they have more complications or they die, unfortunately.

The number, of course, of deaths, more than 11,000 children, more than 24,000 or 25,000 people who were killed. And I believe that this is an underestimate. We always talk about these numbers with skeptical tones, especially the media here. But what I’ve seen in Nasser Hospital in Khan Younis, large number of mass-casualty episodes or events that happens every day because of the missiles, because of the bombing that is happening in urban areas.

That’s the problem with this war, or one of the features of this war. The war is close to everyone. You have 1.8 million people who are crowded in Rafah and Khan Younis area. And the bombs and the missiles are very close to them, which means that many injured people are innocent civilians, especially children.

The number of displaced people in the tents that I’ve seen everywhere – every place I went to there are tents, and this displacement happened to people who have been displaced from northern Gaza to middle Gaza, Deir al-Balah, now to southern Gaza, to Rafah. Rafah had a population of 300,000 before the crisis; now it has about 1.5 million people. You see tents everywhere. No place is safe. So the safe area in Gaza that are perceived as safe area keeps shrinking, and the population in Gaza have no place to go.

One of – some of the other features that I’ve noticed – and my colleagues have noticed – is the fact that, you know, you have shortage of everything despite of the talk in the media and policymakers about increasing aid. I spoke with the head of Catholic Service Relief – CRS – and I went to his warehouse, and he was distributing food parcels to the people in Gaza. And he told me what Gaza needs is not the 100 trucks that are trickling every day, but 1,000 trucks every day – 1,000 trucks every day. And that number amazed me because, you know, like media always talk about increasing aid and going to the 500 trucks that were before the crisis. But 1,000 is what’s needed because there is shortage of food, shortage of clean water, shortage of medical supplies, shortage of surgical supplies. Plates and screws for fractures are not there in the hospitals, so if you end up with a fracture – which happens to practically every patient who is a victim of mass casualty – then you are not going to have the option of having surgeries – corrective surgeries. And you may linger in the ICU or in the hospital for a simple procedure that are not there. There is shortage of insulin, there is shortage of blood pressure medications, shortage of anti-seizure medication. So we need more aid to Gaza.

The prospect of outbreaks – MedGlobal has clinic and twelve medical points in the Rafah area, and we were treating in the clinic about 700 patients. I’ve seen several patients with hepatitis. We could not diagnose it with lab because there is no lab kits for hepatitis, but we diagnosed it clinically, so there is an outbreak of Hepatitis A. According to the WHO, more than 8,000 people in Rafah area have Hepatitis A.

Diarrhea – everyone has diarrhea, especially children, and the respiratory infection – I’m still suffering from the respiratory infection that I contracted in Gaza. It’s probably some type of rhinovirus. Probably there is a lot of COVID, but there is no way to test that.

And also the prospect of multi-drug-resistant bacteria. I think this is something that we don’t talk about, but every patient who end up in the ICU in Gaza has severe wounds, abdominal wounds, perforated intestine, and they are treated with broad-spectrum antibiotics because there is no way to deescalate or do blood culture, and the concept of antibiotic stewardship is not there. So I’m worried about this prospect of increasing multi-drugs – MDR bacteria. That will affect – of course, it cause more sepsis, more morbidity, and more mortality for the long term.

And I will stop on here.

Dr. Morrison: Thank you. Thank you very much. On this question of highly resistant organisms emerging, anti-microbial resistance within the health infrastructure, that predated the war as a problem within Gaza. People knew that this was a problem. It’s no surprise, with the scale of those that have severe wounds and the overwhelming of the system, that you are going to see the colonizing of the medical infrastructure of these highly resistant organisms, and you are going to see young wounded passing away from sepsis in this period. That’s something I think that is going to occur. It’s predictable, and exactly what to do in the midst of that is less clear to me.

There’s been a lot of predictions that we’re on the edge – in February we’ll be on the edge of mass famine. You didn’t mention seeing extreme malnutrition among those that you treated, which is encouraging. Can you just comment a bit on that?

Dr. Sahloul: We have a pediatrician with our team, and our team was seeing a large number of children in the Rafah area. And Dr. John Kahler, who has been with – also with us, with MedGlobal in Syria and other places, in Yemen – mentioned that he did not see what he expected to see in terms of severe malnutrition. He saw several – a couple of children with severe malnutrition. One of them died. But he thinks that his severe malnutrition is related to a different medical issue.

We were told that in the north there is more shortage of food and more signs of severe malnutrition. There is about 300(,000)-350,000 people still in the north with very minimal access to good food or nutrition. UNICEF asked us to establish stabilization unit for severe malnutrition in Rafah area because they are expected to see rising number of severe malnutrition. But at the time we were there, I haven’t seen signs of famine nor severe malnutrition – large numbers of severe malnutrition among children in the Rafah area.

Dr. Morrison: Thank you. We’ll circle back in a few minutes after we’ve heard from Michelle and from Len to talk a bit about the implications of this crisis surrounding UNRWA, which I want – I want to get the opinion of all of our speakers here today.

But, Michelle, over to you.

Michelle Strucke: Thank you so much. Thank you for having me, again. And thank you. It’s wonderful to see Len and Dr. Sahloul as well. Thank you also, Dr. Sahloul, for your admission to Gaza. This is obviously very dangerous work, and really appreciate you consistently going into these conflict areas to serve people.

Today, I wanted to highlight that the cutting off of aid to UNRWA is extremely significant. I wanted to highlight some of the concerns that have been raised by the humanitarian community about it. Even the U.S. government in their response has talked about the fact that UNRWA is an essential part of the infrastructure providing aid into Gaza. Specifically, that just given their breadth and scope, it’s something that – they’re an organization that are not – their work is not able to be replaced or substituted by other humanitarian actors that have access there.

For example, the Interagency Standing Committee – that was the committee established by the U.N. General Assembly in 1991 which is the primary mechanism for both U.N. and non-U.N. coordination of humanitarian crises, they specifically said that no other entity has the capacity to deliver the scale and breadth of assistance that the 2.2 million people need, urgently, in Gaza. Especially considering the scale of the crisis.

And while the allegations are extremely serious, and must be taken seriously, cutting off all of their assistance, particularly from the number of countries that have now done it, is going to be operationally catastrophic. So to give a sense, the U.S. was providing about one-third of the budget of UNRWA every year. And the other countries that have cut off aid account for now about three-fourths of the overall funding that UNRWA needed to be able to survive.

So, again, the breadth and scale is really important because so many of the Gazans that are in need – dire and urgent need of assistance – were relying on UNRWA specifically, whether it be through their shelters, schools being used as shelters, through vaccinations, and important aid to people for health needs. These are all services provided by UNRWA, as we’ve heard before, that now are in peril.

And, for example, the CEO of Save the Children, which is a major – a major humanitarian organization providing humanitarian assistance to children in crises around the world, called it “magical thinking” for governments to think that other aid groups would potentially be able to replace the aid that UNRWA was providing. And some efforts in the U.S. Congress to look at this, by those that are opposing providing the assistance to UNRWA, suggested that other U.N. organizations could pick up the – pick up what they were doing, such as the World Food Program.

I wanted to highlight that this is really unrealistic, considering the fact that UNRWA has thousands of staff across Gaza that are serving people in need, compared with other organizations that have literally a handful. So it’s quite a big difference, and a catastrophic cut that is going to affect a lifeline, as humanitarian organizations – 21 organizations in a statement –highlighted, that this is a lifeline. And they considered it, you know, a reckless decision to cut this lifeline to an entire population by the very countries that had called for aid to Gaza to be stepped up. So these are – this impact is going to be really significant for people, and I wanted to highlight that.

I think there’s another element that is really important to highlight here, which is the conflation, the conflation of distinguishing – we talked about this in our first episode here – the civilian population in Gaza to a terrorist organization. This kind of – this reaction by a wholesale cutting off all assistance to UNRWA, even though that they are – swiftly they fired staff and they are conducting an evaluation/investigation; and they’ve also noted that they did not yet actually receive the allegations in writing from Israel, which I think they need to conduct their investigation – this wholesale cutting off of aid is harming the Palestinians that are, again, existing in Gaza and relying on them for their lifeline. So the enormous harm done by doing it cannot be overstated.

And as we’ve seen in the past, there’s been an effort – and this is a trend. As others can speak to, this is a trend in humanitarian action, to say that aid being provided to a population, perhaps based on their perceived political views or perhaps based on their criticisms of the U.S. in the past or parties to a conflict, it’s often aid given to them is conflated with aiding a party to the conflict. In this case, saying that any calls for a ceasefire or any calls to support the Palestinian population in Gaza are akin to supporting Hamas, these are quite dangerous, this blurring of the lines. And as I learned in my previous work with the U.S. government, distinguishing where a threat really is from where a kind of a common perception of a threat is really significant, because otherwise you end up targeting or punishing the wrong people.

So, again, while the crimes, they are – UNRWA’s staff are accused of are extremely serious, the idea that the whole organization should be cut off, I think, is very problematic. And it’s really important that particularly as the U.S. Congress considers additional funding, and as the State Department and the White House consider how they’re going to potentially and when restore assistance, distinguishing the civilian population in Gaza from terrorist organization – a terrorist organization is extremely essential.

So, with that line, I’ll pass back over to you

Dr. Morrison: Thank you very much, Michelle. I would just add to those really trenchant remarks that it’s certainly not in Israel’s interest to see UNRWA disappear. There are some within the far right in Israel who see it as an emblem of the right of Palestinian return, of the right to a Palestinian independent state, as tied to that, and wishes to – and Netanyahu himself has said he wishes to see it dissolved. But I believe many others are quite conscious that to see an implosion of the humanitarian and health response in the midst of this crisis, when things are already hanging by a thread, would fall – ultimately fall into the lap of the Israeli government, which is not equipped at all to really compensate for that, and it would only magnify what has become a catastrophe into something beyond that.

The other is the suspicion around motives here, where it’s really – you know, lurking in the background is the fear that Gaza’s becoming unlivable; that it is – and that these are – these are forms of collective punishment, in effect. And that, too, is a dangerous set of perceptions that need to be disarmed, it seems to me, through the – through the actions of the U.S. government and others to preserve UNRWA in this period.

Len, thank you so much for joining us and coming to the studio today. You’ve been watching very carefully what is happening on the ground and talking to those, like Zaher, who are operational there. Tell us, what are you seeing in terms of the patterns?

Leonard Rubenstein: Well, thank you, Steve, for having me, and I really appreciate that you’re continuing to hold these discussions. I think that you said it’s the sixth one. I think it’s very important that you’re doing this, and it’s an honor to be here.

You know, back in late October/early November, people were correctly describing the crisis as catastrophic, as unfathomable in terms of the humanitarian cost of this war. And at the time, the idea that it would continue for months longer, into February, was not on anybody’s screen. It seemed impossible that this could go on. But now it has gone on. And what we’re seeing now is the horrors of the north – the bombing, the destruction of housing, the attacks on hospitals, the forced evacuations – have essentially migrated to the south. And it recapitulates what’s happening, with the difference that almost all the population, except the few hundred thousand left in the north, are in the south experiencing this.

And what I’m seeing and what groups are reporting is how the social fabric of life in Gaza is unraveling. Everyone is grieving. Everyone is afraid. Everyone has no – doesn’t know where their next meal is coming from. And just to give you a sense of what daily life is like, OCHA, the humanitarian agency of the U.N., says that 1.2 million people in Gaza are without beds and blankets. That’s what life has become.

There are 17,000 kids who are unaccompanied because their parents are dead or missing. And there’s almost no capacity to support them. Seventy-eight percent of the schools have been severely damaged and destroyed – or destroyed. And there’s no prospect of them being reopened for schooling because they’re needed for shelters. And the shelters themselves in schools – they’re a major source of shelter – they have capacities for maybe 2,000 people, and there may be 20,000 people there. And if you see pictures of what it’s like in the courtyards of the schools and just the crowded conditions, the fact that there may be one toilet for 500 people, you ask how people can live that way.

And of the kids out of school, almost half a million, maybe 400,000, it’s an indication too that the NGOs and the U.N. are making heroic, courageous efforts to meet the crisis. But even with the significant efforts by UNICEF and its partners to provide some support for children, whether they’re unaccompanied or with their families, is a drop in the bucket. And that’s true of all the efforts, whether it’s shelter or anything else.

There are indications of increased domestic violence in Gaza now because of the stress and strain of how people are living. We don’t have good numbers, but that’s the impression that OCHA reported. And then the absence of decent sanitation has led to an estimate of 50,000 tons of solid waste in Gaza now.

Now, imagine what it’s living – like living in that situation and how you keep your dignity, to say nothing of your health. And there’s now unexploded ordnance throughout Gaza. So even people who have escaped a bombing and a shelling, just walking down the street they’re at risk of death.

So that’s the situation for people there. And I think that hasn’t been captured. We see a lot of pictures of people trying to pull people out of the rubble, which, of course, is so terrible. But for everyone there, to say unlivable is really, as you say, not the right word, because people are actually living here without any capacity to live as normal human beings.

So let me turn to the health situation for a moment. Michelle talked about UNRWA. Everybody thinks that what UNRWA mostly does is shelter and education. But UNRWA ran most of the health clinics, the primary-care clinics, about three quarters of which are now out of service. They nevertheless provide primary care in shelters and other places, and they’re seeing 20,000 people a day. (Laughs.) It’s extraordinary that these doctors, and nurses, and other medical staff, who are working endless hours without much opportunity to provide the kind of care people need in primary care, including the medications they need for infectious and chronic disease, they’re still at it. And that’s what UNRWA is doing, among other things. And that would be a cost of losing UNRWA. Groups like MedGlobal and others have finally been allowed in, outside groups, outside NGOs, or NGOs that were there are finally being allowed to bring more people in. But imagine how they’re going to serve 20,000 people a day.

So that’s kind of what it’s like, I think. And then when you turn to the hospitals, what you see in in the south is bombing and shelling around and at hospitals. Al-Nasr is the biggest one, but the others, including Al-Amal, which is run by the Palestinian Red Crescent Society, where they also have their headquarters in the south, in Khan Younis, has been shelled. And there have been incursions by the IDF. And these are places where thousands of people are also taking refuge. So this combination, as Zaher said, of incredible shortages, incredible workload, and yet they’re continuing, under attack.

And on top of that, when Israeli forces go in, they often detain the health workers. More than 150 health workers have been detained in hospital incursions. Most released, but often after being stripped naked, and interrogated, and humiliated. Some have not been released. And the same is true for ambulances. Dozens and dozens of medics and drivers of ambulances and medical transports have been arrested at checkpoints – even when they’re with WHO or MSF, which everybody knows. Some have been killed in these incidents.

So we have this other crisis on top of the ordnance crisis against hospitals, and the violent entry. You have the psychological as well as the personal effect of seeing your colleagues being arrested, detained, and mistreated. So that’s kind of the picture that we have now. And all I can say is we can only hope that these negotiations for a ceasefire, which is the only thing that’s going to stop this, go through. And on that note, we’ll find out soon enough when Israel has to send a report to the International Court of Justice. But it’s not clear, from my vantage point, that anything much has changed since the interim measures were adopted.

And we can talk about this later, but I think in some ways the enormous international focus on the International Court of Justice has distracted attention from the real source of accountability, which is International Criminal Court investigations of crimes against humanity and war crimes. The prosecutor, Karim Khan, visited the region in December, committed to investigate. And, in fact, committed to take on interpretations of international humanitarian law, which I thought was an allusion to Israel which is reinterpreting the law, to what he called denuding it of meaning.

And that’s an important development. And there should be encouragement, advocacy, discussion that has been kind of silenced by the overwhelming interest in the ICJ proceedings. I’ll stop there, and we can talk about this more.

Dr. Morrison: Thank you. Thank you very much. I’ve got a couple of key questions, but I want to – before we delve into those, I’d like to come back to Zaher and Michelle for any reactions to what we’ve just covered here.

I know, Zaher, you witnessed from your – from your bedroom in Rafah – you witnessed some of what was described here. I’d like you to talk about – a bit about the conditions that you observed, in terms of security, and the prospect of an assault upon Rafah. I mean, I think what Len has described is powerful, but we’re right on the edge of the possibility of the offensive that you described, how the realities of the north are migrating into the south. The front edge of that is the prospect of an assault – the siege of Rafah. That is – in terms of the military calculations, that is on the table today and people are wondering about that. And what would that mean? Zaher?

Dr. Sahloul: I want to just underline what Len has mentioned, and this is something that we don’t talk about a lot, which is the psychological impact of attacks on health care in the north to health-care workers in the south. And the closest example, I would say, I’ve seen to this crisis where hospitals and clinics are becoming the center stage of a war is Syria, where we had systematic attacks on health care that led to huge displacement of the population and depriving communities of health care in Aleppo and Idlib. And we know that there’s still 7 million Syrian refugees. Half of the population are also internally displaced.

So it’s happening again, unfortunately, in our lifetime, this time in Gaza. Maybe not the same targeted attacks with double tap that we’ve seen in Aleppo, intentional, but it’s there every day. One of the nights my team and I were in Khan Younis in Nasser Hospital, which is the largest tertiary center still operating now partially in southern Gaza. Khan Younis is five miles north of Rafah. And there were continuous bombing. Actually, I opened the window from the ICU and you see the bomb. You see the smoke rising. You see the drones, the fighter jets nearby. It’s about one mile away from the hospital. At night, there were continuous explosions that are very close to the hospital. And I looked at the faces of my colleagues, Palestinian colleagues, and they had all flashbacks. They have seen what happened in Shifa Hospital or Rantisi Hospital, Kamal Adwan Hospital, Indonesian Hospital in the north, where you had doctors humiliated, detained; some of them were beaten by the IDF. And they started leaving the hospital on foot at 3 a.m. because they were fearful that they will end up with the same situation – that the hospital will be under siege, IDF will come in, they will detain them, they will strip them naked, and that’s – or they will be injured and they will linger in the ICU, disabled. Many of these doctors and nurses, by the way, are themselves displaced from the north and they live in tents. So they wake up in the morning, they try to get water and bread to their family before they come to the hospital. So imagine the situation and the mental health trauma and the pressure on them with this war situation that is endless.

Rafah by itself right now is becoming the only refuge of the 1.5 million people that left the north and they were displaced from, you know, six or seven times until they end up in Rafah. And if the IDF overrun Rafah, I think that will be the point of no return, as we discussed yesterday. This population have no other place to go. There is the Mediterranean, and then you have the border with Egypt that is very heavily guarded. There is no way for anyone from the Palestinian side to get to the Egyptian side. And I don’t think that the geopolitics will permit Egypt to allow a large number of Palestinian refugees. Even the evacuation has been very slow for patients who are dying, actually, waiting to be evacuated. So if the IDF said what they wanted to say to get into Rafah, I think that will be even worse catastrophe than what has been described and what I have witnessed and our team have witnessed.

I give it actually to the doctors and the nurses in Gaza. Despite of everything – and to the people of Gaza. They were patient. They were honorable. They were generous with their time, with their limited resources and food. They were very happy that a group of five doctors from the United States came to them. I did not see them angry or bitter about the situation. They were hopeful for this war to end so they can focus about the rebuilding. But at the same time, every person I asked whether they wanted to leave Gaza, they said yes, because this is terrible. They’re not going to be able to rebuild what has been destroyed for the foreseen future. They don’t have houses. They don’t have universities anymore. Many of the hospitals are not operating. And they’re not sure whether they will be able to live in Gaza. Any person who is able to leave Gaza is leaving Gaza. And that’s what is making this situation worse than – or, much different than the previous wars that happened in the same area for the past 16 or 17 years.

Dr. Morrison: Thank you.

Michelle.

Ms. Strucke: A few things to add. I think, one, it’s worth emphasizing in the humanitarian situation that – and this doesn’t make any headlines anymore – but electricity is still out. The fact that some basic services are still being denied to the population is something that I think is worth more discussion, because the ability to access – to even call emergency services is disrupted by widespread blackouts of communications and network disruptions. The workarounds that Palestinians and Gazans have tried to create to get cell phone service are only available to a limited segment of the population. And with electricity, of course, that’s a huge barrier for the ability to facilitate the functioning – the appropriate functioning of medical equipment in hospitals. And the continued issues with fuel also, not having adequate fuel being allowed in, is also, you know, hindering that operation.

Another thing to highlight too about the context is that humanitarian access requests that the U.N. has made are not always facilitated, particularly in the north. So OCHA has reported recently that they made 22 requests to – from the U.N. to the Israeli military to open checkpoints early, which – in areas north of Wadi Gaza, and they were all denied. And I think that’s a significant thing to point out, because these issues mean that early movement is really essential, considering the volatility of the conflict, the congestion. Again, Gaza is one of the most densely populated places in the world. And with, you know, nearly all of the population now currently displaced, that’s obviously contributed to even more crowding.

So these elements demonstrate the fact that obviously, under humanitarian law, parties to the conflict have to facilitate access. It’s their obligation to ensure that the population is really receiving their needs met and it’s done in a dignified manner. That’s a word that Len used today, that dignity is an important part of humanitarian response. And it’s hard to imagine a less dignified situation than the one the Gazans are experiencing. And what Dr. Sahloul just discussed about the incredible, generous patient character of people that are in such danger, living in such conditions, in tents, while trying to provide medical services and humanitarian assistance – it’s an incredible testament to the character of people in Gaza.

But that being said, it is not – their character doesn’t relieve the parties of an obligation to ensure that humanitarian aid is being scaled up and facilitated. And, again, on the topic of the day to day, I worry that the chilling effect that we could be seeing of the cut off of aid, of countries having this more knee-jerk reaction, is going to have a longstanding effect. And that effect – that devastating humanitarian effect – will be borne the backs of the Palestinians who are dying and experiencing this incredible, undignified state of suffering.

Dr. Morrison: Len, your thoughts?

Mr. Rubenstein: Going back to your question about Rafah, we’re hopeful that these negotiations about a ceasefire and hostage and prisoner exchange will succeed. If they don’t, that is going to create an even worse situation, as Zaher said, that there’s no place to go in Rafah. And its – (laughs) – we’re running out of words to use to describe what could happen. But what it would require is much more aggressive policy by the Biden administration. It’s the only player that can – has any way of compelling Israel to moderate its stance, much more than the International Court of Justice or any anyone else. And to date, the administration has used jaw boning, and persuasion, and sometimes criticism, but hasn’t really imposed any severe consequences.

And, for example, in the bill pending in Congress right now to – well not clear what’s pending exactly, after the – (laughs) – after yesterday’s development in the House of Representatives. But it still is resisting any conditions on arms transfers to Israel. And it just has to do that. And as, Steve, you know, we wrote about this, it has to take a stronger stance at the U.N. Security Council, and not veto measures that would make serious demands on Israel for ceasefire and other actions. That is going to have to happen if the ceasefire doesn’t go through. The administration deserves a lot of credit, and Secretary Blinken despite all the criticism, for working so hard to try to get negotiations not only started but to succeed in bringing about a ceasefire and more humanitarian access. But if that doesn’t happen, the status of Rafah as well as the rest of the Gaza Strip, is absolutely going to demand much more aggressive action by this administration to end this cataclysm.

Dr. Morrison: You know, the discussion we’re having right now, in a way, is circling around this question of what would the priorities look like? Let’s say we get to a moment where there is a ceasefire, of some – a phased ceasefire of some kind, and phased release of hostages and detainees and prisoners, and a phased reopening around the humanitarian agenda, what is it that we should be pressing for as top-line priorities in that? And we’re beginning to get some answers from you. I mean, one is these questions around the U.S. being tougher on the Israelis, in the ways you’ve described, Len. It seems to me that’s a very important element.

A second is, restabilize UNRWA and make sure that it does not implode or become victimized through a series of measures that sort of drag this out versus restore it to its functionality. Its budget was running – its budget pre-October 7th was 15-16 million (dollars) a year in Gaza. It tripled to almost 50 million (dollars). And Tom White and others, Lazzarini, have said the actual demand and need is well above that, probably two to three times that level, in order to meet the requirements. So we can’t take that most foundational pillar of response and eviscerate it, and hope that there’s going to be a turnaround in the humanitarian situation if you have some kind of deal, fragile deal, that’s sealed.

Seems to me also we have to be very vocal about what the expectations are of Hamas, in terms of diversions, use of civilians as human shields, and release of hostages. And that shouldn’t disappear from this rhetoric. In terms of – there’s been reference to opening the sights, opening the gates, and getting much higher volume of trucking traffic in, with the key ingredient – key elements that are needed. Right now, it’s averaging 100 or less trucks per day, with very strict and cumbersome bureaucratic inspection requirements. In talking to the U.N. folks involved in this, they’ve said that if the circumstances were improved, they might reach 260 or 270 trucks per day, organized through the sort of humanitarian channels.

But they can’t get to 1,000. They can perhaps get to 300. But that says there needs to be a market restoration. There needs to be the ability for market forces to come back in with confidence in their security and their ability to sell their goods. That was – and when there was 500 a day pre-October 7th, it was overwhelmingly market-based. It was not humanitarian. So I think we need to be cautious about not thinking that – on the humanitarian side – that the international NGOs and agencies are going to get to 1,000 trucks. I think they could get to perhaps 300, with a struggle. But then you really got to be thinking about restoring a market in order to avoid a continued deterioration of circumstances. And the story that you’re all telling is of a continued decline and a continued regression in this period, that we thought was unthinkable a while back.

Over to you, Zaher. Your thoughts?

Dr. Sahloul: I agree with everything that you said, Steve, especially about increasing the commercial activities into Gaza, because there is no way for the NGOs or the U.N. to meet the demands of the population that are increasing by the – by the minute.

In term(s) of aid, it’s not only opening the three border crossing, which right now only one is open but even – Rafah border crossing is open partially, but Kerem Shalom, of course. And we’ve seen demonstration trying to block the entry of goods from Israel to Gaza from Kerem Shalom. And also Erez. And why aren’t we considering even airlift? I think the United States has the capacity and the influence to do airlift of essential goods into Gaza, and that would bypass the bottlenecks that we – seven or eight bottlenecks that we have for any truck to get into Gaza. In our way from Cairo to Rafah, to Gaza, there were thousands of trucks that are stuck at the Egyptian side, and I cannot explain this phenomenon after 123 days of war. So commercial trade should be secured.

For trucks to distribute goods inside Gaza, there is need for fuel, which – there’s a huge shortage of fuel and the fuel is very expensive. Cars are actually operating on cooking oil in Gaza because there is no fuel and it’s quite expensive. So there is a – there is a need for more diesel fuel for the trucks to operate and transport the goods from place to place.

And also communication, that Michelle has mentioned. Without communication, you cannot – you cannot distribute large – you cannot run an operation, large-capacity operation, of distribution. You need to tell people to come and pick up the food parcel or the personal hygiene kits or the dignity kits, and without communication it’s impossible. And of course, the lack of electricity is hindering all of this.

So also, I mean, for the day after – hopefully, we will reach a point I will talk about, the day after – there is a need for a huge operation of rebuilding. And temporarily, people will be in tents, and people understand that. In the north, people will be in tents for a long time because everything that preserve life or resemble normal life has been destroyed, including schools and universities and hospitals and things like that in neighborhoods. But there is no proper tents inside Gaza. There is a need for proper tents that preserve the dignity of the population where you have maybe four or five people in a tent instead of the 20 that we have right now.

I went to some of the tents that have been built with plastic sheets because there’s no proper tents inside Gaza. People in the shelters are crowding in a situation that is sub-humane. I went to one of the schools, Fadila School in Rafah, where it has – every class has 40 or 50 people. One of them was an obstetrician who had a C-section the same day, and she was discharged from the hospital to this class that has 40 other people with her newborn baby. So imagine the situation on a woman, on a pregnant woman, on an elderly, on someone who is disabled. And there are many of them in Gaza. So I think all of these issues should be taken in mind, not only the number of trucks from Rafah.

You know, I have a habit of asking children in a warzone: What would you like to be in the future? And nine out of 10 Palestinian children in Gaza, they tell me, “doctor.” They want to be doctors. None of them told me I would like to be a fighter, which was surprising to me, you know, fortunately. I mean, we had the perception that people wanted to fight and stuff like that. They wanted to be doctors. They wanted to be engineers. They wanted to be teachers. Only one kid, he was in this Al-Fadila School, and he was standing by and looking at the medical (coin ?) that we had. And I asked him: What would you like to be in the future? And he said, “what future?”

I think the people in Gaza need hope; need someone to tell them we will rebuild what has been destroyed, and you can have dignity, and you can have something that you dream about as a child, as a woman, as an educated person. Ninety percent of the population in Gaza are educated. They care about education. They have high standard. And I think these issues we have to discuss more, how the day after will be for the 2.2 million people in Gaza.

Dr. Morrison: Zaher, I’m very happy that you turned to this question of what will provide hope, how to sustain hope in this situation. I think that’s a theme we want to close on in the course of this hour because I don’t want to close on an overly pessimistic note. This is a terrible situation as we have described it, but we need to return to this – to this theme of what will be most effective at turning things around and restoring some element of hope.

I want to ask Michelle to comment on that, and Len, and then we’ll come back to you, Zaher, for closing thoughts. We’re getting near to the end of our hour here. Michelle?

Ms. Strucke: I think to have hope, to have the dignity and the needs play a larger role in the foreign policy considerations, there are some policy steps that definitely the U.S. government can take to help and try to facilitate this, especially because the problems we are seeing here are really a matter of political will. The U.S. could have a – basically see that the situation that people are facing is unacceptable and draw more red lines. There are – obviously, the U.S. is such a strong ally to Israel that looking at the foreign assistance, the military assistance they are providing – to ensure that it’s in line with human rights obligations and is not doing more harm than the good that they are seeking to do through military operations to protect Israelis. I think this is really important to look at that foreign assistance – to have political will to look at humanitarian solutions with a wider brush, thinking about the ports – a port that could be opened, greater crossings, facilitating more safe routes for delivering humanitarian assistance, and then emphasizing the need to protect humanitarian workers so that they can actually provide aid.

If these kinds of concrete steps were taken, I think that would provide more hope, and especially if basically the level of what is considered acceptable by those that are part of the conflict to allow for civilians that are trapped in the middle, I think – right now, that level of what is acceptable for them to endure is far too low. The bar has to be higher so that people can have hope to know that they deserve to have food, they deserve to have water, they deserve to have electricity, they deserve to have a functioning toilet. These are the kinds of things that I think would give me hope if I saw a stronger response from the U.S. to make these. Foreign policy is always a balancing, but to balance higher the civilian needs that are existing with the objectives to support our – you know, the U.S. ally.

Last, ceasefire discussions certainly provide a small ray of hope, but that being said, the parties have to have the political will to get across the finish line to make that happen, and then once they do, it can’t be business as usual in this conflict. It should be a huge surge of assistance that’s allowed. And I think we did not see as much of a surge last time as was required.

So there is some hope, but it requires people to make hard decisions.

Dr. Morrison: Thank you so much, Michelle.

Len, your closing thoughts?

Mr. Rubenstein: I haven’t been to Gaza since the war began. I’d been there in the past, but I can’t tell you what I’ve heard what people in Gaza want that would provide them hope. But I can speculate that the hope could come from knowing that this is the last war, and that the whole Palestinian-Israeli conflict will be resolved, the occupation will end, and there will be a road to a Palestinian state; not an endless road, a road with some milestones and achievements that will result in having the kind of life people in other parts of the world have where they have a government that they – can represent their aspirations and not be under the thumb of a military occupation. I think that has got to be the way forward and may be a source of hope for them.

Dr. Morrison: OK, thank you, Len.

Zaher, you get the last word here today on our hour-long conversation.

Dr. Sahloul: I just want to highlight something that we did not highlight today, which is the goodwill that I’ve witnessed from many people from diverse backgrounds in the United States and all over the world about what’s going on in Gaza. I have not seen a community or communities engaged in a crisis, a global crisis, like what I’ve seen right now in Gaza. And I’m sure that Len and Michelle and yourself kind of had the same observation.

Hope can come by removing the barriers between the Palestinian diaspora in the United States, the Arab diaspora, the Muslim diaspora, the American people who care about what’s going on in Gaza – and there are many of them – and Gaza, at one point, where this goodwill can be translated into large operation of rebuilding of Gaza, of planting hope. Of connection, the people of Gaza to the diaspora, to have a future for the children who need education, for the disabled who will need to be evacuated to maybe the United States to be – to get treatment, for the people who are suffering unnecessarily right now because they are in this open-air prison for the past 25 years. Many of them are descendants of refugees.

I think removing the bottlenecks and the barriers between the diaspora, the communities who care about what’s going on in Gaza, is the best way to plant hope in Gaza. Let’s not just leave it to the governments. Let’s not just leave it to the U.N. But for the people who care about the Palestinian people in Gaza and their plight, and I think if we can translate this goodwill into meaningful action that will be the best hope for the future of Gaza.

Dr. Morrison: Thank you. I want to offer a special thanks to Michelle, Len, and Zaher for taking the time to be with us today and for their leadership and their courage and commitment on this cause, and this colossal challenge – complicated challenge, that we’ve attempted to sort of make sense of here and to focus on what are the concrete steps going forward. I’d also like to thank those who have joined us online for this hour.

We will post this video on the CSIS homepage, CSIS.org. We’ll expedite a transcript that will be a companion to that video very soon. And we will move to our seventh episode soon as well. So stay tuned for that. Again, I want to thank Sophia Hirshfield, Alex Brunner, and Dwayne Gladden for their support in making this all possible. So with that, we’re going to draw this sixth episode of “Gaza: The Human Toll” to a close. Thank you.

 (END.)