Implications of the Blinken/Austin Letter and Sinwar's Passing—Gaza: The Human Toll
Available Downloads
This transcript is from a CSIS event hosted on October 22, 2024. Watch the full video here.
J. Stephen Morrison: Good morning, good afternoon, good evening. I’m J. Stephen Morrison, senior vice president here at the Center for Strategic and International Studies, CSIS, a Washington, D.C.-based think tank.
This is the 20th episode of the CSIS broadcast series Gaza: The Human Toll. It’s a one-hour broadcast. It’s a product of the CSIS Bipartisan Alliance for Global Health Security and it’s a collaboration with our colleagues here at CSIS. I’m joined today by my colleague Michelle Strucke, who directs our Humanitarian Agenda program and our Human Rights Initiative. Our Middle East Program, led by Jon Alterman, is also a partner in this.
I want to offer special thanks to my colleague Sophia Hirshfield, who works assiduously on each of these episodes in getting things organized and executed. I also want to thank our remarkable production team, Eric Ruditskiy and Dwayne Gladden, who have expertly put together, along with Qi Yu, these 20 episodes.
The video and transcript for this show will be posted on the CSIS homepage. That’s CSIS.org.
We’re very honored to have two truly exceptional guests with us today.
Dr. Hanan Balkhy is the director of the WHO Eastern Mediterranean regional office, based in Cairo. She assumed that position on February 1, and from that very moment has been exceedingly active across the region with a very special focus, for obvious reasons, on Gaza, West Bank, the escalating war in Lebanon. She’s a physician with special expertise in pediatric medicine and antimicrobial resistance. She received her training at King Abdulaziz University and did her residency training at Mass General and the Cleveland Clinic.
We had the honor of hosting Dr. Balkhy here at CSIS September 17th. She did a wonderful conversation with my colleague Katherine Bliss, which you can find on the CSIS homepage, on that day. And we hosted a high-level dinner. The level of interest in her and her role, it was exceedingly high here in Washington.
We’re also joined by Dr. Shira Efron. She is the Diane and Guilford Glazer Foundation senior director of policy at the Israeli Policy Forum. Previously she spent 15 years in think tanks in Washington, most notably leading the RAND Corporation Israel Program, 2016 to 2022. She’s among the most highly respected and cited sources on Israeli policies and has special expertise on Gaza. She completed her Ph.D. and M.Phil. at RAND’s graduate school.
Welcome to you both.
We’re in a period of profound developments, and we’ll hear more about those from our speakers. I want to highlight right now, for a second, the October 13th letter from Secretaries Blinken and Austin, the secretaries of state and defense, to Yoav Gallant, Israeli minister of defense, and Ron Dermer, minister of strategic affairs in the Israeli government. This letter marked a departure from past policies in a number of ways.
Let me just quote. We’re now writing to underscore the U.S. government’s deep concern over the deteriorating humanitarian situation in Gaza and seek urgent and sustained actions by your government this month to reverse this trajectory. It’s increasingly dire, the humanitarian situation of over 2 million Gazans.
Aid deliveries have dropped by 50 percent. Israel must, starting now and within 30 days, act on the following concrete measures, which I’ll summarize. And the argument here is that U.S. law, under the Foreign Assistance Act, requires that there be adherence to international humanitarian obligations and that those are going to be enforced in the future.
They’re looking for a surge of all forms of humanitarian assistance through Gaza, with very specific numbers; commercial and Jordan armed-forces corridors function at full strength, and the isolation of northern Gaza; cease the attack to undermine UNRWA through legislative action; facilitate the International Committee of the Red Cross access; and establish a new channel through which we can raise and discuss civilian-harm incidents. Our engagements to date have not produced the necessary outcomes.
So this marks a departure from previous policies up to this point. It certainly is the most concrete statement of U.S. policy, setting a 30-day window.
Obviously, we have many other profound developments that are happening in the war itself – the decapitation of Hezbollah leadership, crushing of Hamas leadership, the death of Yahya Sinwar, and the intensification of violence across multiple fronts.
In northern Gaza, around the Jabalia refugee camp – we’ll hear from Hanan, I’m sure – the aerial and ground operations by the IDF has intensified, as has Hamas demonstrating its ability to strike. The 300(,000) to 400,000 people that are living there in displaced status have had a total cutoff of relief, virtual total cutoff, since October 1.
There’s a specter of which it becomes completely untenable for this population to stay there and raises the question of whether this is driven by – will result in the expulsion and clearance of the north.
In Lebanon, we know there’s the escalation by both Hezbollah and Israel of aerial attacks upon the other’s soil, with huge humanitarian impacts in terms of displacement, injury and death. In the words of the U.S. envoy attempting to mediate between Hezbollah and Israel, things have escalated totally out of control in recent days – 1.2 million displaced Lebanese in the past week or more, 2,400 dead; displacement, obviously, within Israel of over 150,000; as we know, in Gaza, continued 101 hostages.
The Israeli-U.N. front itself is a – is part of this war – 250 U.N. workers killed; continued violent confrontations that the U.N. is experiencing; efforts in, as we mentioned, in the Israeli government and legislature to legally undermine UNRWA. So the confrontation between the U.N. and the Israeli government itself is one of the fronts.
And we know that there’s a threat of further escalation and retaliation by Israel against the Iranian attack.
So as we look at this there’s the question of where do we go from now, what are the prospects for peace. Prospects for a negotiated settlement have been dim but now we have Secretary Blinken back in the region attempting to explore what kind of options there may be for a cease fire long term or temporary, release of hostages/detainees, and bringing the – expanding dramatically humanitarian access.
Gaza in this period is both obscured but also brought back to center stage. But that center stage in this multi-front war that’s expanding is much more crowded than it has been to now.
So which brings us back to why we’re here. We’re here to hear from Dr. Balkhy and Dr. Efron what does this mean and how do they see things, and what are our options, looking forward. So thank you both for joining us.
I’m going to turn to Dr. Balkhy first to lead off with her prepared remarks and then we’ll turn to Dr. Efron, and then we’ll have a conversation with my colleague here Michelle Strucke. Thank you both for your leadership and for making the time to be with us.
Over to you, Dr. Balkhy.
Dr. Hanan Balkhy, M.D.: Thank you. Thank you very much and it’s nice to see you again, and I’m really happy to be able to put the perspectives from the WHO in this conversation.
Since the atrocities of October 7th, 2023, a wave of shocking violence and bloodshed has erupted across the region, as you have mentioned. The resulting situation in Gaza is one of the greatest humanitarian tragedies of our time. Six percent of the population has been killed or injured, a quarter of people injured over the past year now requiring long-term rehabilitation in a setting where these services are almost not existent anymore.
Eighty-four percent of Gaza is under evacuation orders with medical personnel and patients among those forcibly moved. The risk of famine remains extremely high with 86 percent of the population at above crisis levels for food insecurity.
Diseases are spreading with polio making a comeback at Gaza after 25 years. The risk of spread both with Gaza, within Gaza, and internationally remains high given disruptions in the routine vaccination and damaged water and sanitation systems. Humanitarian pauses during the ongoing polio vaccination campaign show that we can be achieving some kind of hope through political will and prioritizing health.
The number of critically ill patients requiring medical evacuation has now risen to 15,600 with only 5,130 evacuated over the past year. Since the closure, of course, of Rafah border crossing on May 7th only 234 patients have been evacuated to other countries. WHO, of course, has been highly active in orchestrating some of this work.
Recently in Qatar and a few months ago in Egypt I have met patients who had been successfully evacuated for medical care. It has been a very difficult interaction with these patients. Many of them are alive today because they received treatment that is no longer available in Gaza.
However, these successful evacuations are increasingly exceptions and certainly not the rule. WHO staff in Gaza told me about a 2-year-old boy called Riad suffering from leukemia. He died just yesterday morning in Nasser Medical Complex. His family had been waiting for medical evacuation since September 19 and there is currently no cancer care or chemotherapy available in Gaza.
The closure of the Rafah border crossing, previously the main entry point for the delivery of health supplies into Gaza, has also significantly impeded our ability to deliver aid at the scale that we need. Other entry points into Gaza such as Kerem Shalom border crossing are unreliable and poorly accessible.
And even when we are able to send patients into Gaza our efforts – supplies, sorry. When we are able to send supplies into Gaza our efforts to deliver them to health facilities are fraught with additional challenges. In the first two weeks of this month alone, only three out of 16 planned aid missions to hospitals across Gaza were facilitated, while only 81 percent – while 81 percent were denied, canceled or impeded.
What remains of Gaza’s health system is overwhelmed. Less than half of all hospitals are functioning, and only partially so, so that they face shortages of staff, fuel, medical supplies, safe water, and food. In north, only two hospitals are operating at minimum capacity. And there are no operational primary health care centers. Just a few days ago, a mission by our team to Kamal Adwan Hospital faced immediate setbacks with fuel and blood supplies denied delivery at the last minute, and only patient transfers allowed.
So we’re facing immense challenges, not only in providing critical health service but in safeguarding the lives of those delivering them. Today in Gaza perhaps the most dangerous place in which the U.N. and partners operate, with more than 300 U.N. staff killed since October 2023. We’re also deeply concerned about the escalating hostilities in the West Bank, resulting in more deaths, injuries, displacement, and damages to civilian and health infrastructure. Military operations, increased settler violence, checkpoint closures, and health worker detentions are severely restricting access to health services.
The expansion of the war into Lebanon is also extremely troubling. Over 2,400 people have been killed and more than 11,000 injured since last October. And according to the Ministry of Public Health – those are – that’s the data that we have been receiving – the U.N. has not been spared, with two U.N. colleagues and one of their sons killed, and the U.N. peacekeeper wounded while on duty. So Lebanon’s health system, already devastated by an economic crisis and repeated shocks, is struggling to cope with this last – this latest escalation.
Frontline hospitals are severely understaffed and medical supplies are critically low, unable to meet the demands of increasingly growing number of injured people. Hospitals have suffered damage, forcing evacuations of staff and critical patients. Since last October, 47 attacks on health care in Lebanon have killed 95 health workers and injured 77. As a result, nearly half of primary health centers in conflict zones are closed due to damages. Six hospitals are nonfunctional and four are only partially functional.
Since the escalation of hostilities, WHO has been sounding the alarm on diseases like cholera resurfacing in Lebanon as a result of poor water and sanitation conditions and the impact of the conflict. On October 16th, the Ministry of Public Health confirmed a cholera case in the north of the country, marking the first case since the last outbreak was declared over in June 2023. More than 780,000 people are now internally displaced, straining overcrowded shelters and increasing the risk of disease spread. Over 420,000 people, including Lebanese and Syrians, have also fled to Syria, where the health system has been decimated after more than a decade of war.
For over a year, WHO and its partners have repeatedly called for an end to the conflict in Gaza, Lebanon, and across the region. These calls remain unanswered. I recently traveled to New York and Washington, D.C. to meet with government and humanitarian partners. I warned that the current crisis poses a global risk, including outbreaks of diseases such as polio, cholera, AMR, and many others. I pushed for stronger diplomacy to deescalate hostilities, protect civilians, and prioritize health. I also flagged that funding gaps that are – that have hindered our response to rising health needs. We received reassurances of continued support to protect health and wellbeing in our region.
Finally, to respond effectively we need immediate and unimpeded humanitarian access. Hostages must be released unconditionally, a lasting ceasefire achieved, and work towards a just and sustainable peace initiated. Without these steps the crisis will worsen, with the humanitarian consequences reverberating far beyond this region.
Thank you very much. And back over to you, Steve.
Dr. Morrison: Thank you, Hanan.
Dr. Efron, thank you for joining us. We know that the traumas of October 7th live on, the concern with the 101 still remaining hostages inside Gaza, the huge displacement north and south, stresses upon the economy, loss of life and injury among the soldiers deployed, economic consequences, international isolation. This has been a war that has had profound impacts felt internally within Israel itself in the midst of this broader catastrophe that Hanan has so ably detailed, starting with Gaza but talking about West Bank and what is happening in Lebanon. Share with us your thoughts on what’s – on what you’re seeing.
Dr. Shira Efron: So thank you for having me. I really appreciate this program and elevating those voices of what’s happening on the ground.
And as Hanan says, the situation on the ground is catastrophic. You know, right, even in hell there are different levels, and I think that if we look around the region now Gaza probably tops all other fronts, so maybe I’ll focus on that.
I will just say that, you know, it’s – October 7th did do something to Israel that I had never felt before, right? It upended the sense of security, which is something that Israelis are not used to. And in the minds of Israelis, there was – this is not a war of choice; this was a war that was imposed on us. We could describe, you know, the nature of the war, the course of the war, and this is a long conversation. But this is sort of the Israeli mindset.
And in addition to the other implications that this war has had for Israel, I’ll just say that I’m sitting in, you know, Tel Aviv now, but my kids today had to run to the shelter as I was driving to the office because we had sirens and drones and rockets fired nearby. So this is ongoing. But of course, we can’t – we can’t compare. So I will try to focus on Gaza, but really happy to answer any other questions.
I won’t repeat any of the statistics because Hanan gave us a really good overview of what’s happening on the ground, and it is a humanitarian catastrophe by all standards. I will just start with, like, a few truths, at least, that – when it comes to Gaza. And I think some of the things we’re seeing now in Gaza, obviously, it’s unprecedented, but those are continuations of things we’ve seen throughout the years.
So we can talk about technical issues, right? We could talk about what do we do with sanitation, what do we do with infectious diseases, and vaccinations, and – but really, those issues are highly politicized. We have all the technical solution. This is a manmade crisis, and it’s a matter of a decision – decision by all.
I know there – I’m not an international – I’m not a lawyer and I’m not an expert on international law. I think a lot of people are looking for the answers in international law and putting liabilities on the Israelis. I won’t go into that because I don’t think that’s where the answer will come from.
To me, the situation in Gaza we can – we can divide the blame as we like; I don’t think it’s helpful to engage in the blame game of who’s at fault. It represents a collective failure. And actors that you mentioned – sort of the U.N., Israel – which being – is another front, the two sides. And it’s not just the U.N., right; the humanitarian community at large in Israel have actually more shared interests than they like to act on, and this would be very important to move forward in terms of how to ameliorate the situation. I think it will be very difficult to speak about fixing it, but at least let’s stop the deterioration, improve the lives of people on the ground.
From the Israeli perspective, I think there is a paradox when it comes to Israeli policy vis-à-vis the Palestinians in general and to Gaza in particular. I think Israel likes to disengage from the civilian aspects of managing the lives of the Palestinians, but on the other hand it wants to control the security around everything. And this is a paradox, because if you want to dictate the terms of every garbage disposal container that goes in it’s going to be very difficult to actually let actors on the ground do their job. And this is an issue.
It seems to me that everyone is – or, not everyone. I’ll talk about the Israeli perspective. We’re drowning in the details itself, but there’s no whole strategy. And I’ll get to it in a moment.
Whether we like it or not, and I’m not trying to protect anyone here in Israel, but the images that you all see every day on international media of babies dying, and burning alive, and mass forced evacuations of people, and everything we’re seeing from Gaza, the Israeli public is sheltered from it. The media here enacts self-censorship. I don’t think it’s correct, but the mindset in Israel is that we don’t even know what’s happening in Gaza. Obviously, I do, but I think the general mindset in Gaza. And there is a perception that there is no humanitarian crisis in Gaza.
I know you all think, how can that be possible? But when you’re shielded from the data and when only one body is responsible for interpreting the data, saying we averted humanitarian crisis, that’s why you hear a lot of – you hear voices in Israel saying, why are we providing Gazans with humanitarian assistance? Which, obviously, Israel doesn’t provide anything. It just enables. And we know this is limited, as you read in the letter. But why are we providing them? We should – they’re getting things they should not be getting. This is the state of mind here. And it’s a terrible one, but it is – it is the fact.
And then I do hope that with Secretary Blinken’s visit and the letter that you read, we will see some room for improvement. I’ll mention in a moment where I see the points where we can leverage. But I will just say that when we – I look – I’ve been studying Gaza for many, many years, primarily those technical aspects. And in November/December, starting to look at what can – where can we fix. And I said, instead of looking at, like, one – you know, the wash, the sanitation crisis, so let’s just look at the big things. And if you look at sort of, like, from the donor to the beneficiary, this whole humanitarian supply chain, we have big issues all along the way.
There is donor fatigue. There is misalignment of needs. There is monitoring that is not happening. Aid still comes through – primarily through Egypt, even though Rafah is now closed. There are the limited cross – the routes. There are the limited crossings. Now Israel controls all of them, and obviously Israel needs to open them and make sure they’re operating in full capacity and open more of them. There’s this situation inside Gaza, right? How do you protect aid and aid workers? How do you distribute it? How do you – the capacity issue. And then in terms of – and the failure of Israel – or, the refusal of Israel to speak of any viable day after option, and this goes to the political issue, it makes it much more difficult to come up with durable solutions.
When we talk about things where I – what I would like to see – and you know, in – and I don’t want to take up too much of our time, but when we look at – the primary actor that engages with the international community on Israel’s behalf is an IDF body, part of the Ministry of Defense, COGAT, the Coordinator for Government Activities in the Territories. And they’re primarily engaged – you know, sort of like the crossings, right? They can say, like, OK, what do we bring in? But after – what’s happening in Gaza, it’s not their problem. Or, at least that’s what they’re saying, it’s not their problem.
How do we engage with the donors? What kind of picture we would like to see? How do we define humanitarian crisis? To me, the fact that 650,000 kids have not gone to school in a year, this is part of the humanitarian crisis, right? It’s not just, like, not having diverse foods. But this is not even in the criteria. So if I were to fix this, and if I – I’ve advocated for this a long time ago. But I think this is where the United States, you know, you’re an American think tank, obviously. Elevate this issue. This should be not managed by an IDF body. This should be managed at the prime minister, Ron Dermer level, because this is a strategic issue and it merits their highest attention.
I would also argue that, you know, this whole U.N. representing also NGOs, I would say, like, the U.N. is sort of the head of the international humanitarian community, but there are issues also with different NGOs that needs a rapprochement, a whole – excuse me – a whole couples therapy for Israel and the U.N. This is something that the U.S. needs to be doing, finding a way to all work together. There are no visas now for humanitarian workers who want to work in Israel. New organizations that are not registered – pre-registered in Israel, they can’t work in Gaza. This creates complications that are – it’s against the interest of the state of Israel. I’m not even talking about just Gaza, right?
If we look at pre-positioning aid, this whole idea that trucks keep coming in and then the goods are offloaded to a Palestinian truck, this Palestinian truck can drive or not drive and you can find a truck or you cannot find a truck, there are so many things that can be done. We can create a list and I can talk to you about everything from a garage for fixing generators to trucks, which are a rare commodity in Gaza, to fixing infrastructure, to preparation of Gaza for the winter, for moving into emergency recovery. But it’s also a matter of a decision.
And maybe I’ll just end with I – there’s some cynicism, I think, in Washington that this letter gave 30-day notice to roll it into the transition after the U.S. elections. But the perspective in Israel, at least it’s been taken very, very, very seriously. This language was not anticipated, even though they knew something was going to come. This is seen as a stark warning. And we’re already seeing the prime minister ordering a surge in humanitarian supplies.
I hope this will be leveraged into action and shifting away from just counting trucks to measuring outcomes. And, you know, probably we can talk about what does actually mean, and transitioning to what we need to do, which now the emergency recovery. Altogether, a lot of it would have to do, I think, with consistent U.S. involvement.
And I hope that, no matter who is elected, this issue will continue to be a priority, because I’m sitting here on the Israeli side of the border, but I really, truly believe there is a moral imperative, but also strategically. It’s not in Israel’s interest, it’s not in the regional interest, not in the U.S. interest, but it’s also not in Israeli interest, to have such a great humanitarian crisis at its doorstep.
Dr. Morrison: Thank you so much, Hanan.
What was the reaction, where you sit, to this U.S. letter? What did you make of it? How significant is it? It’s a very specific letter. It’s stark, as Shira made clear. But it’s also very, very specific on what the metrics are going to – what the expectations and metrics are, vastly beyond anything that we’ve seen so far. And it’s making the judgment that the U.S. law, the Foreign Assistance Act clause, has to be applied now. We have not heard anything as definitive or categoric as that up to now. How has that been viewed and understood where you sit, Hanan?
Dr. Balkhy: Thank you. Thank you very much.
I think, of course, as you said, the difference now is the clarity and explicity that existed in the letter. And from a WHO perspective, from a humanitarian perspective, we are very much looking forward to the type of pressure that can be placed so that the sustained aid can continue. And we’re always welcoming the increased concerns of the humanitarian fallout in Gaza, as we have all seen.
And it’s – you know, as you know when I was on the previous interview with you, I have been to the West Bank, and I was in Gaza during the month of July. And I have seen with my own eyes the situation on the ground, whether it’s from the – as Shira was mentioning, it’s all public-health issues. But these are – this is the reality of the people on the ground who are significantly suffering. It’s about a humanitarian issue. So that’s one part that’s extremely important, that it acknowledges that.
The second thing is that we, of course, welcome that type of acknowledgement and pressure that can move things forward in the right direction. But I think the reality is how is this going to translate in reality on the ground in Gaza and West Bank, and also in Lebanon? And how will it be sustained? And how can we start building for the day after as soon as possible?
Over to you, Steve.
Dr. Morrison: Thank you.
Michelle. Michelle Strucke, please join us.
Michelle Strucke: Thank you. So much incredible information to respond to.
I think, just on the letter, I think it demonstrates to me an increasing visibility of the turmoil that exists within the U.S. government around these issues. There have been information shared in press about dissent essentially about clearance around the weapons issue a few months ago and now the fact that the letter lays out these specific humanitarian concrete actions I think is a real opportunity to be able to link the –pretty much what seems to be the only pressure point that has any impact, which is arms transfers, the leverage that the U.S. has substantially around arms transfers.
The frustrating thing, I think, as we watch that unfold is just that last time even though the United States paused a weapons shipment and that did lead to substantial humanitarian improvements under the former envoy Satterfield –
Dr. Morrison: This would have been in April.
Ms. Strucke: Exactly. That did lead to those – in my view, it seemed to be connected to those improvements. I’m not in either government so hard to say.
But the frustrating thing is that the – even though there were improvements it was still such a low bar that we’ve now seen the emergence of near famine conditions, and my concern is that even though that letter enumerated a list of things that are concrete humanitarian improvements that by any standard will alleviate suffering but not at all to the extent that’s going to be required to alleviate the huge humanitarian spillover and catastrophe that we’re seeing, I am not convinced that – you know, that they’ll hold it to the standard that’s in the letter.
Basically, I’m concerned that the U.S. government will take with this administration any small improvements to say that they’re – the government is listening and doing more. And so I think the bar is something that – of what is acceptable for humanitarian catastrophe and actions in terms of delaying and denying aid are really significant and things that need to be looked at.
I also agree that getting beyond trucks as a metric it’s extremely important. But the stat we’ve had since the very beginning it was 500 trucks going into Gaza pre-conflict and now with the immense historic humanitarian needs the U.S. government’s only demanding 350.
And the other issue, of course, which others have raised is the operational environment within Gaza that makes it extremely difficult even if you get a truck inside to be able to distribute that aid and protect the aid workers that are risking their lives to deliver it.
So those things, I think, are extremely concerning. We haven’t talked yet in this conversation much – I know it’s been in the news lately – about the number of children that are impacted and really just kind of the pace of the conflict and how unprecedented that is.
I just want to bring that up, that Oxfam recently looked at some data from the U.N. children in armed conflict reports noting that in the last – over the last 18 years no other conflict killed a higher number of children in one year. So we’re seeing absolutely historic levels of children impacted here.
And in terms of the pace, just to bring up that Israeli explosions hit on average homes every four hours, tents and temporary shelters every 17 hours, schools and hospitals every four days, and aid distribution points and warehouses every 15 days.
The only reason I say that is because we’ve had so many of these broadcasts where we’ve had incredible experts talk about how it’s happening in that period between now and the last episode, but to look at it holistically over the past year and say this pace is unprecedented. This is not a pace that we see in other conflicts of violence and I think, again, my concern is the U.S. ability to impact the conduct of hostilities and that pace is – we’ve seen it to be very limited.
The leverage they do have – this letter is an interesting moment to see will they actually hold to that standard of making them demonstrate concrete improvements and a change in the conduct of hostilities, especially as this has expanded.
Dr. Morrison: Thank you.
Hanan and Shira, would you like to respond to that?
Hanan?
Dr. Balkhy: Well, thank you, Stephen.
No, I think I agree with a lot of what has been said and it seems like we’ve said earlier in this discussion we can start about the technicalities of issues and the health impact and the public health issues, and then there’s the political aspect of this.
What I would hope that this dialog ends up highlighting to the political decision makers to hear and to understand how devastating the situation is and that this really needs to move forward to a political decision that we can end this war and start moving forward with rebuilding what’s happening.
I’m very concerned we talk about what we see today but the impact that I want to also add – maybe it was not clear in my opening statement – is the impact on the people for the decades to come: the orphaned children, more than 10,000; the maimed; those who have – are going to be having major disabilities. The fact that we’re going to be facing huge needs for mental health assistance. And in one of the reports that I’ve heard, one of the physicians was saying that already everybody in Gaza and in the West Bank probably has some kind of mental health stress one way or another. So you can imagine what’s happening now is only going to make things worse. And that’s not good for the region in general. So maybe those are what I wanted to add. Thank you.
Dr. Morrison: Thank you.
Shira, I want to frame a question to you. You know, when we look at this war, there have been different points at which terrible things have happened that have resulted in increased pressure on both Israel and Hamas. You had the April 1st killing of the World Central Kitchen workers, and the – and the April 4th statement by President Biden, very harsh statement. And then you had improvements in access over April. Many of those were reversed when the – when the southern front campaign began May 6th. But you had – you had that.
You had the outbreak of polio, the evidence of polio, end of June. You had international pressure intensify on both the Palestinians and – I mean, the IDF and Hamas. And you had the first round of polio vaccination, with very effective temporary pauses. And 560,000 children under 10 successfully vaccinated in that first round.
Now you have the September – I mean, the October 13th letter. And it seems to me that given those precedents, that letter raises the possibility that there will be a motivation, certainly on the part of the Israeli side – I don’t know where the decision process is in Hamas post Sinwar’s death – but to consider a return to things that are quick intermediate steps, like temporary pauses or temporary ceasefires, and for expanded access and the like.
I could see those options being entertained now as a way of – because that 30-day window ends pretty soon. And from October 13th, it’s already 10 days into that 30-day period. So how do you see that? Are these temporary – this period of escalated pressure and the specifics, are we likely to see more exploration of this? There’s a reference in one of the – one of the press accounts today that Secretary Blinken in his conversations is discussing these types of options.
Dr. Efron: Yeah. So, listen, you referenced it, and I’ve written about it. I think that Israel voluntarily did not change its humanitarian policy, but it had evolved substantially over the last year. If you remember the first days, I don’t have to repeat statements made by Israeli officials. They’re all documented in a lawsuit in the International Criminal Court, right, in the Hague. So but there has been an idea of what is possible – some sort of an idea of a siege in Gaza. And obviously in response to pressure that came also before the World Central Kitchen tragic killing of staff members, there were other points where the U.S. was able to get Israel to approve entrance of goods, to open crossings, to increase the numbers, and others.
It only came as a result of U.S. pressure. And that’s why I do think the U.S. has leverage. This letter is very extreme. I don’t think – I would have hoped, as an Israeli, Israeli American, doesn’t matter, I would have hoped that Israel wouldn’t get to this point. I don’t think it was needed, in terms of the Israelis, right? Why did we have to get here? But I do think that the U.S. has leverage, as we’ve seen before. And it could have had more leverage, leverage that would also be political, and start those conversations about the day after.
Reportedly, Blinken was going to come here and they also want to leave some legacy, right? So not just talking about short humanitarian pauses, but also talk about some day after plan. Well, the initiation of this day after, it could have come when the U.S. developed – brought in this pier, which was really – (laughs) – quite a fiasco, right? What we call JLOTS, the pier. But it could have enforced a Palestinian Authority presence monitoring the pier; the crisis around the Rafah Crossing, which it wasn’t able to solve. So my hope is that the U.S. will use its caliber, right, as the leader of the international community, not just talking about a few hours of humanitarian pauses and how many – by the way, there is the second wave of inoculation/vaccination today; it’s very – or, yesterday. It’s quite – it’s quite successful, which I think to me is a demonstration that when the – when the international community and Israel want to work together they can do so very effectively. And we should build on these successes.
But my hope is when Blinken comes here that he makes it clear to his counterparts that this should be elevated into a strategic issue. We can speak even – if I were designing the system, I would say we need to have a committee that deliberates the data and assesses the situation on the ground. It can’t be that on every little thing in Israel, you know, every person in the government has an opinion, but on the interpretation of the data in Gaza and whether it is humanitarian crisis or not it comes only from one IDF body. This – deconfliction issues.
And I have to tell you, the positive news, I guess – if there’s any positive news – is sort of like the intense war in Gaza, finished, and we are moving into some sort of counterinsurgency fighting. This war needs to end. In practice, it ended, right? So now it’s the time to look after those children and next generations, because, as we said before, right, the implications are going to be felt forever. And if Israel is interested politically in deradicalization and having a peaceful neighbor, that sure is not the way to get there – (laughs) – right, from an Israeli perspective.
Now, there are initiatives. I can tell you know, you know, one, there is a model of a youth village for unaccompanied children. And there are many of them, thousands of them in Gaza now at the moment. Having a place that they would be safe, there is a lot of endorsement and support for that, by the way, including in the Israeli system. I think that if we have a few success stories, it would be very – I know it’s less ambitious, but as you’ve pointed also, Steve, right, let’s have a few success stories, let’s prove that we can get done, show to the Israeli public that the sky doesn’t fall when you move forward, and take it from there. Because at the moment, where – what I am really scared of is also that the international community – I know not people like you, right, but I think that I’m hearing voices from the U.N. headquarters in New York that say we’re done, we’re almost done; we can’t handle this, this is too difficult. And I hope we don’t get to this point.
So there is plenty to do. And I do think that the U.S. can bring Israel to do this and put their leverage also, by the way, on the Palestinian Authority where it’s needed, the U.N. to be less principled at times, and also Egypt can be a more constructive partner.
Dr. Morrison: Thank you.
Hanan, your thoughts? And one thing I’d like you to speak to is, you know, we know that Hamas retains some capabilities of fighting. That’s part of what’s happening in the Jabalia refugee camp. But its leadership has been – has been largely destroyed. What are you hearing from the communities themselves in Gaza? And are we at a moment where it’s possible for a different form of engagement and security in answering some of these – some of these really challenging things? And related to that, are you in fear that we may be heading inexorably into a steady emptying of the north into the south?
Dr. Balkhy: All of these are extremely critical questions that I wish that someone would have clear answers to. But I think the reality on the ground and what we’re seeing is that there continues to be significant continued displacements of children and families over and over again. So that’s the reality on the ground that we’re getting from our teams and from what we’re seeing every day still taking place. On the – so that remains very concerning.
I wanted to address the issue of the polio campaigns and how challenging it was, but yet very successful, especially for the first round. The second round, as we will start going into the – eventually into the north, we do hope that it would be successful as well. As a pediatrician, epidemiologist, and maybe very scientifically oriented person, it’s not done until it’s done. And until we actually see the numbers, the reality of those 90 to 93 percent of the children below age five above two months of age have been vaccinated, then I have to be very cautious about calling this successful, because the reality is if we do not succeed in reaching the scientifically based goals of vaccinating and immunizing children polio will continue to circulate and, unfortunately, the easiest blame will come to the WHO.
For me, it’s not about being blamed. You know, it’s not about WHO. I really could – you know, when you see people dying, you know, significantly and all what’s going on, it’s not about our reputation only. It’s really about us getting rid of a very difficult disease that people who end up suffering with it suffer for their whole life. And I just hope that we will be able to successfully continue on the second – on the second round.
The other fact, which I was happy that Shira brought it up, is the education issue. The children that have not been educated have also not been vaccinated on their primary vaccinations. And when we really look at the reality, I think the hope that the world can see – and perhaps also the protection of the – of the community and the word “neighbors” becomes very important because this polio immunization campaign is protecting, truly, the people of Gaza, but the reality is the Gazans who are fully engaged in this campaign are protecting the world despite them being under all this significant pressure and being in the warzones, if you will.
So I think some of these issues need to be highlighted over and over again. And we need to – from my side, I’ve been asked that question again, as Shira mentioned, whether the U.N. will give up. I don’t think we would ever give up, at least from the WHO perspective. We need to continue to support our member states. And I would like to give a lot of credit to my country offices in the EMRO region, which is beyond just Lebanon and Palestine.
But in all of the crises that we’ve been facing, we stay and serve. Our only impediment are two. Number one, the ability to get the visas and to be able to go in at ease, and the footprint that we’re allowed to have, and our security of course. Number two is the funding issues. Other than that, we remain on the ground serving our mandate. As a member state organization, we have no intentions to back out, or off, or away. (Laughs.) And we feel that we have a major role to help the people on the ground. Over to you, Steve.
Dr. Morrison: I’m going to come back to Michelle in a moment. Shira, any thoughts to add to what we just heard from Hanan?
Dr. Efron: No. You know, it’s so – I agree, it’s not – it’s not done until it’s done. And these are – right, it’s real things. We can’t – this is physiology and biology and physics. This is not something that – there’s no narrative, right? We have to get to a number of children under a certain age. And thankfully, Gaza has had a very high inoculation rate, certainly than – I don’t know, I lived previously in California – than areas in California that were antivaccination.
And I think that helped save, by the way, also Israel, because there were cases that I remember looking at even before the war, right, on meningitis and other diseases happening in Gaza. And, you know, this is – it’s a cliché, but viruses, germs, environment, it does not know borders. So I do, you know, agree with everything that Hanan says. It definitely protects the people of Israel, and the rest of the world, and this region.
What I would like to – you know, what – and I was relieved to hear the WHO is not going to give up. I think what we are hearing from New York, coming from the political leadership of the U.N., and obviously the political leadership of Israel, but there is – there is a blame game that is happening. And it’s also, sadly, affecting, I think, working teams on the ground. And we need to address that, and try to think of explaining why – instead of why we can’t do something, and who is responsible for it, how do we work together?
And lessons learned from the polio campaign can really be helpful in the winterization effort, right? We need to prepare Gaza for winter. It’s a mild winter in this region, but we have 90 percent of the population displaced and in tents. It’s still going to be a very difficult winter if we don’t make very, very urgent preparations. And I do hope this is something Secretary Blinken – they mentioned it in the letter – but that they actually act on it in a very serious way going forward in the next couple of months.
Dr. Morrison: Thank you. I know Michelle – we have a few minutes for another quick round of conversation. I want to turn to Michelle.
Ms. Strucke: Thank you so much for all of these comments. I mean, I think what we’re seeing is just – and this is what’s so frustrating – despite how many people are working on this issue, how many people are risking their lives, we’re still seeing not even a bare minimum of aid getting to people in need, and a bare minimum of political action that’s needed to end the conflict. If you look at the fact that the funding, which Hanan talked about in terms of what WHO needs, member states have only distributed 1.89 billion (dollars). That’s only 55 percent of what’s needed of the 3.42 billion (dollars) needed to meet needs in Gaza and the West Bank, which includes East Jerusalem. That 55 percent is not even close to enough, when you think of what we’re seeing unfold.
We also need stronger diplomacy. That’s been said over and over in this conversation. I fully agree. We need – it’s great that Secretary Blinken is in Israel today. That kind of engagement, as well as engagement with the Israeli population in order to explain what is going on and what is at stake in terms of the humanitarian crisis, is absolutely essential. And that diplomacy should include the things in this letter, which I know they are saying behind the scenes and now we’ve seen in public eye. But there need to be more emphasis on lifting the commercial import ban and getting those commercial trucks in, rescinding evacuation orders so that people aren’t continually displaced, and addressing the kind of political concerns that this could be, you know, an effort to sort of empty northern Gaza. The winterization, which we’ve talked about, pushing on that.
And I want to say too that, to me, there’s a lot of talk about the – kind of the timing of the letter, and how this relates to the elections. I just want to point out that this is well beyond an election issue in the United States. This is a generational issue. And I think that’s what we’ve heard today. This is a generational issue that will haunt public officials in the U.S., in Israel, in Jordan, in Lebanon, in Syria. People are fleeing to Syria. We heard that today. I mean –
Dr. Morrison: Hundreds of thousands.
Ms. Strucke: Hundreds of thousands. This is something that is going to last, in my life, at least the next 15 years. And I want to just point out one more thing, which is that we have the ability in these conversations – I would say the luxury, definitely for me, to sit here and read reports, talk to experts, but I’m not there seeing what’s happening. And yet, a lot of this kind of conversation framing is happening online.
The fact that there are these absolutely horrifying videos circulating since the conflict began, but in particular the one of a child and another – and his older brother literally burning alive in the Al-Aqsa compound, who died. You know their names, Abdulrahman and Sha’ban. The fact that people are watching this happen and then thinking about the role and the choices their governments are playing, this is not something that’s going to go away after an election, no matter who is elected in the United States.
So I think it’s in everyone’s interest to put the future ahead of the present moment and think about the impact on American security, on Israeli security, on Palestinian security, well beyond the talking points that we keep hearing and the sort of half measures. It’s hard to have this conversation 20 times and see where we are. Thank you.
Dr. Morrison: Thank you very much, Michelle.
We’re at the close of our hour. What I’d like to ask Shira and Hanan to do is just offer us some brief thoughts around what are the core messages you want to leave with our audience? Our audience is predominantly a Washington-focused audience – not exclusively. We have people tuning in and watching. This will be posted on our home page. We get enormous traffic coming from various ways. But let’s start with Shira. What message do you want to – what’s the – what’s the top line message, or two or three messages, that you want to leave with us here at the conclusion of this hour?
Dr. Efron: I will say, to, I guess, the U.S. crowd, I think there’s a tendency in Washington to, you know, on the one hand, speak about the humanitarian, talk about the talking points of what needs to be done now, and then talk about this long-term vision of a two-state solution, but not connecting the dots. And I do think that, if done right, the humanitarian effort, turning into emergency recovery, and maybe one day to reconstruction, could help you also achieve the political vision. So doing it right and be bold in your initiatives.
Think of the whole thing in terms of, you know, take a holistic approach, work with partners, and understand the role of the United States here. I agree, this is a generational issue and this message has to be sent across – and the U.S. is the leader of the international community. If it’s not the U.S., no one else can.
And I would just say, you know, we’ve had here a year of bloodshed and destruction and a war that’s now, on multiple fronts, right – we’re not going to compare the suffering of the different people. Obviously, we’re talking about Gaza here. And if the United States, as the leader of the international community, does not seize the moment and turn it into a serious diplomatic effort for finally not managing the conflict and not looking, OK, when they go here or there, but really a serious effort.
We’ve seen this administration – I think this administration was the first one to actually ignore the Israeli-Palestinian conflict, right, complete sideline it, thinking they can do stuff without it, and it came biting them back. And, you know, the key message is use this and look at the humanitarian effort as another component in the future of the region, you know, to come, both technically and politically, if you will.
Dr. Morrison: Thank you, Shira.
Hanan, what messages –
Dr. Balkhy: Thank you.
Dr. Morrison: – what messages do you wish to leave with us today?
Dr. Balkhy: Thank you. Thank you very much.
I think it’s very difficult to – for me, getting, you know, flashbacks of videos is one thing, but flashbacks of what you see with your own eyes is a totally different level of suffering.
I have maybe a few comments. The first one is I totally believe and know that the U.S. has the largest leverage. And I really wish that the U.S. will do everything that they can to make sure that diplomacy plays a critical, immediate role to end the suffering. That’s the first request.
The second one for, as you said, that the audience is the American crowd, as you said, is that this humanitarian crisis is absolutely real. And I think it would only take a few seconds to see some of those videos to realize that they’re real. And I can tell you that they are real. There’s lots of physicians that come from U.S. entities and academia that have served in Gaza. It would be great for them to hear from them firsthand, the people that they trust, to tell them about the realities of the patients and what they’re going through on the ground to better understand the complexity because, again, hearing it from the people on this side of the world and also from the U.N. entities where they may not trust anymore for several other reasons is a problem for us. They need to have the information from the people that they trust.
And I think that the U.N. and their response is a – the American people and the whole world, all member states need to understand that the U.N. is a member-state-driven organizations. We do our work based on our member states executive boards. We’re not an NGO. We’re not working on our own. We are part of the global community.
With that being said, what we do is to fix some of the problems that Shira said, and I want to repeat what she – a manmade humanitarian crisis. This is a manmade humanitarian crisis. And so we need to have solutions to it. I hope that this suffering can stop soon.
The one last thing is that if anybody sees anybody suffering, regardless of their color, their religion, their beliefs, we’re all at the end humans. Every individual in this world wants to have a family, wants to be safe, wants an education, wants to see prosperity for their kids and their grandchildren. And for me as a person, I wish that for everybody on this Earth. And I’m pretty sure that if we use that message that everybody deserves a decent, respectful life with dignity – and the people in Gaza are deprived of all of that right now. They have no dignity left. And that, for me, is really sad, and I really hope that the American community – the U.S. and the whole world can see that so that we, you know, leverage all the diplomatic potential to make this end.
Thank you very much.
Dr. Morrison: Thank you very much.
We’re at the end of our hour. This has been an extraordinarily powerful and timely conversation. I want to offer, really, the most sincere thanks on behalf of Michelle and myself to Dr. Hanan Balkhy and Dr. Shira Efron for taking the time to be with us today, to be so incisive and so open and candid with us, and for your commitment and your leadership, which are so extraordinary at this moment.
I want to thank Michelle Strucke for joining us; our staff – Sophia Hirshfield, Eric Ruditskiy, Dwayne Gladden – for all of their support in making this possible. I want to thank our audience who’s with us.
The video and the transcript will be posted on the CSIS homepage. That’s www.CSIS.org. And stay tuned for our future episodes. Thank you so much.
(END.)