Is it Possible to Avert Collapse?—Gaza: The Human Toll

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This transcript is from a CSIS event hosted on December 15, 2023. Watch the full video here.

Jon B. Alterman: Good morning and welcome to CSIS. I’m Jon Alterman, senior vice president, Brzezinski chair in global security and geostrategy, and director of the Middle East Program.

And I’m pleased to welcome you to the fourth edition of Gaza’s Human Toll, the series that CSIS has been running since November 13th. As the world watches the war in Gaza, the effects on the civilian population, the series is intended to help us understand what is happening with civilians, what is possible to happen with civilians, what can be done to protect civilians who are trapped inside a war zone just about twice the size of Washington, D.C.

We seem to be at an inflection point in this conflict. National Security Adviser Jake Sullivan is in Israel. He met with the leadership, accompanied by the U.S. humanitarian coordinator for this war, David Satterfield, and met with the Palestinian leadership as well. The president talked earlier this week about Israel’s indiscriminate bombing in Gaza.

The other possible inflection point is in the health field, where we see increasing numbers of children, other civilians affected by infectious disease, by waterborne illness. And many people who are on the ground, humanitarians, are worrying that we may actually see an explosion, not so much in combat deaths but in health effects from civilians trapped in a conflict zone.

To discuss this, we have a really remarkable panel. We’re joined from New York by Lana Wreikat, the acting director of global emergency programs for UNICEF.

We will be joined shortly, coming to us from Jerusalem, by Rik Peeperkorn, the representative for occupied Palestinian territory for the World Health Organization.

We have Steve Morrison joining us from Seattle. Steve, of course, is traditionally the host of this program. He is a senior vice president at CSIS and the director of CSIS’s Global Health Policy Center.

And here with me in the studio, Leonard Rubenstein, Johns Hopkins University Bloomberg School of Public Health and the author of a landmark study, “Perilous Medicine: The Study to Protect Health Care from the Violence of War,” published two years ago by Johns Hopkins University Press.

So Lana, you have people on the ground in Gaza. What do you see happening? What’s changing? How urgent is the situation right now?


Lana Wreikat: Good morning. It’s a pleasure to be here. And thanks for inviting UNICEF to give this briefing.

I’ll start first by saluting our national colleagues who are on the ground staying and delivering for children despite the devastation of their homes, families, and communities. We have around 30 colleagues, national, and we have almost four international colleagues. And we have also hundreds of police, not only at the site of Palestine, but in the region. And globally we are working day in and day out to advocate for programs and deliver in Gaza.

It's been now over two months since the renewed escalation of hostilities in Gaza with an intensity rarely seen before. October 7th attacks were horrific, with over 1,200 Israelis and foreigners killed and over 200 others taken hostage, including children.

We work for all children. So we really advocated for the release of children hostages. And we actually continue to advocate and work with different actors so that we ensure that the release of all hostages, as well as detained children.

The situation in Gaza is catastrophic, with hostilities making meaningful humanitarian efforts nearly impossible. Inside Gaza there is nowhere safe for 1 million children to turn. The parties to the conflict are committing grave violations against children. And these include killing, maiming, abductions, attacks on schools and hospitals, and the denial of humanitarian access.

If you want to look at the numbers, more than 7,000 Palestinian children have been reportedly killed. This is over 150 deaths average per day. Children now make up 40 percent of the casualties. From 1.9 million people we have 900,000 children who are now displaced from their families, living in shelters, which are severely congested. The sanitation and hygiene conditions are deplorable as well, with some shelters even having only one toilet for 1,400 people. And these are under constant bombardment.

I hope we will get to speak about the water situation, health, and the different sectors. In terms of access to safe water in Gaza, it’s deteriorating each day, with many only accessing three liters per day per person or less. Water scarcity and unsafe sanitation elevates, of course, the risk of disease. And we are already seeing increase in children’s respiratory infectious diarrheal diseases, skin infections, among others.

The health-care system is also nearing total collapse and hospitals partially or completely nonfunctional due to damage from attacks and lack of fuel and supplies. There are an estimated also 50,000 pregnant women in Gaza, with the equivalent to more than 180 babies being born every day. So an increasing number of new mothers and babies are at high risk of death the longer the hostilities continue.

We do acknowledge the huge efforts of many to secure medical evacuations, including member states and agencies out of Gaza, including small newborns from Shifa Hospital, which UNICEF was part of this effort. However, there remains many more that continue to need evacuation to proper care, and those numbers will continue to grow.

In terms of nutrition, all children inside Gaza now are food insecure. Over the next few months, child wasting – which is the most life-threatening form of malnutrition in children –could increase by 30 percent in Gaza. These are conservative projections, actually. And the longer the conflict and siege continue, the higher these figures will rise. And children could eventually die while the whole world is watching. We are also concerned with the increasing number of unaccompanied and separated children, as well as the fact that children in Gaza will likely face long-term psychological impact from this war due to repeated exposure to trauma. So mental health now is a big issue.

Education is the passport to a better life and future for children in Gaza, but all children in Gaza are now deprived of the right to education with the ongoing hostilities and almost 90 percent of schools damaged or destroyed. This crisis really represents an unprecedented disregard of civilian lives, particularly children, reaching a critical inflection point really marked by collapse of social services, mass displacement, looting. It’s becoming really very difficult for our teams to operate.

And despite this highly complicated situation, from the very beginning UNICEF responded to this crisis. We have pre-positioned water and health, sanitation, and hygiene supplies in Gaza that we distributed at the onset of the crisis. And when the crossing border from Rafah opened, we had 185 trucks with lifesaving supplies going in. And with support of partners, we have been able to reach over 1 million people in the past few weeks in Gaza with safe water and almost 200,000 people with hygiene supplies. We also have been working to support sanitation and cleaning services in shelters, hospitals benefiting almost 500,000 people.

And we have been able to also get medical equipment and supplies through the border to help sustain the operation of existing primary health-care centers and hospitals. To date, we have delivered health supplies for almost 470,000 people. Additionally, we have been offering emergency cash transfers to families when possible, and we’ve reached almost 300,000 individuals.

But this is definitely nowhere near enough to meet the overwhelming humanitarian needs. And the majority of these delivery were possible during the pause. There is much more that needs to be done. And the humanitarian community cannot do it alone. We also need the private sector to be supported so that they also get in and provide basic services. And we need the markets to be up and running to meet the entire population of 2.2 million people needs.

Of course, I’ve mentioned the humanitarian pause that allowed UNICEF and other partners and partner organizations to bring lifesaving supplies and support. But a temporary pause is not a solution. We do need full humanitarian access restored and ceasefire. Children’s lives and futures depend on this.

Dr. Alterman: Thank you, Lana.

Len, you’ve thought about this from a legal perspective, from a public-health perspective. What’s the legal framework for the sorts of things that Lana was describing?

Leonard Rubenstein: Thank you, Jon. It’s a pleasure to be with you, and an honor to be with this incredibly distinguished group of speakers.

As Lana said, there have been innumerable attacks on hospitals in Gaza. Two-thirds are not even partially functioning. But as the ground invasion has taken off in the last weeks, we’ve seen the same kind of brutality and violation of the laws of war in those operations with respect to patients and hospitals as we saw in the attacks on hospitals with respect to duties of proportionality and minimizing harm to civilians. And there were three dimensions I’ll briefly mention.

One is, Israel has claimed, of course, that hospitals are being used by Hamas for military purposes. There’s a lot of controversy about whether that’s the case and, if it is the case, whether it’s the case in all these hospitals. But putting that aside, even if it’s true Israel still has a duty to minimize harm to the patients in the hospitals. And that’s a very important obligation. In fact, the wounded and sick have special protection, not only to respect them – that is, not attack them – but protect them to make sure their medical needs are met.

But what we’ve seen in the Al-Shifa Hospital siege and assault and more recently in the Kamal Adwan Hospital siege and assault it’s quite apparent that the Israeli Defense Forces made no efforts to provide the water, the food, the medical supplies, the electricity, that were missing in the days of the siege and before that and at the time of the assault the situation was catastrophic and people were dying.

But there is no indication that any serious efforts were made to save the lives of people who were at great risk. In Al-Shifa there were public relations statements about bringing boxes of medical supplies into the hospital and later incubators for babies who were dying. But those were a drop in the ocean.

There was no effort to address the overall situation. At the same time in these assaults, in fact in the last couple of weeks, two women who had given birth in a maternity hospital were killed inside the hospital in sniper fire.

The second concern is – has not gotten much attention, which is the detention and abuse of medics. There’s a shortage, of course, of health workers in Gaza. Now 300 have been killed, some in their homes, some in hospitals. Some have left if they’re associated with international humanitarian organizations that are foreign nationals.

So there’s a huge shortage and the medical staffs are stressed out, and yet there were serious numbers of arrests of medics in the course of these assaults. And beyond the assaults in a convoy organized by WHO and the U.N. – and U.N. agencies last week there were detentions of Palestinian medics with the Palestinian Red Crescent Society, which is an organization that has always been respected and admired for its integrity and its compliance with humanitarian norms.

People were arrested, they were beaten, and it was only the intervention of WHO that got them released. But during the delays involving the interrogation and detention of those medics a patient in critical condition died because of the delays. An MSF convoy was also attacked. Multiple convoys were attacked. In fact, the WHO convoy was also shot at.

So we have not only lack of protection of medics on the ground but arrests and shooting at them.

The third issue is safe medical evacuation. Over the last 20 years Israel had developed means to coordinate safe evacuation during fighting in Gaza. The ICRC did the coordination work and acted as a go-between between the IDF and the humanitarian groups.

That has basically disintegrated and there has been very little effort to make sure there is safe evacuation even when groups like MSF and others have arranged with the IDF for a path and a route so it will be safe. But it hasn’t been safe.

An MSF nurse, as I mentioned, was killed in one of those convoys and humanitarian groups have had to cease many evacuations from hospitals in the north which had been required by Israel because it’s too dangerous and they can’t count on any safe evacuation.

In fact, WHO has spoken on this quite publicly, which is itself extraordinary, because the system just isn’t in place. And so we have the kind of exacerbating factors after all the airstrikes, after all the harm and suffering from those that people in hospitals, in transit, can’t get out and the people treating them are subject to abuse.

Dr. Alterman: So let me ask a question: Who does this the right way? I mean, a lot of countries in war feel that they’re busy fighting a war. Certainly when Russia does this, Russia’s not respecting international humanitarian law. A lot of combatants don’t respect international humanitarian law. In your experience, who does this right? And the other layer is, of course, in Gaza there’s no way to evacuate everybody from potential conflict zones and so there’s – and when the U.S. had an assault on Mosul and supporting the Iraqi army’s assault on Mosul, you could move the civilians out. As you think about who does this right, does the United States always do it right, sometimes does it right? Does anybody really do it right?

Mr. Rubenstein: First, you’re absolutely right that Gaza is such a unique situation because people are hemmed in and they cannot leave. There’s no place to go. There’s no place safe, and the area where the – more than a million displaced people in the south are penned in is itself unsafe.

Dr. Alterman: Eighty-five percent of the population is displaced right now.

Mr. Rubenstein: Yes, that’s right. And the answer to the question of who does it right, here’s a paradoxical answer. Israel did it right. During the Second Intifada 20 years ago, there were many killings by Israeli Defense Force soldiers of Palestinian medics in the course of medical evacuations and there was a major outcry, and the politics were really right. The leadership in the defense forces were concerned, political will existed, and the procedures were changed. And what happened was, in the intifada, the Second Intifada, evacuation became safe. And in the wars in Gaza over the last 10 years, those procedures remained in place. As the political environment changed in Israel, with more right-wing and anti-Palestinian sentiment, there were many more breakdowns, but still there were efforts to continue that coordination system to make sure safe passage existed. And that seems to have completely been abandoned and at a time when the need for medical evacuations at a huge scale has increased. So the answer to the question is Israel knows how to do this. They were a pioneer in developing these procedures. But it seems to have been left behind.

Dr. Alterman: Steve, we’re waiting for Rik Peeperkorn. We have not seen him yet. I was wondering if what Lana and Len said is prompting urgent comments on your part before we hear from Rik.

You’re muted, I think.

  1. Stephen Morrison: Thank you. Thank you, Lana and Len. And special thanks to our crew – Eric Ruditskiy, Qi Yu, Dwayne Gladden, and Dhanesh Mahtani – for putting this whole show together. And thanks, Jon, for hosting.

There’s a couple things at this particular moment that sort of jump out in listening to Lana and to Len. One is the state of the population. I mean, the civilian population, when we step back at the 10th week now and ask what kind of condition are they in, it’s a pretty wrecked condition. I mean, there’s galloping infectious diseases. Malnutrition is becoming more and more severe; it’s being documented by NGOs. The trauma and mental health consequences are becoming very visible. But now we’re seeing lawlessness and breakdown of basic order and people in such desperate needs beginning to sort of take matters into their hands, into their own hands, and that’s another signal that local governing institutions and confidence that something in the midst of this desperation will happen is eroding. People have gone through multiple displacements; there’s no path out. And I would argue that this deterioration of the population is accelerating towards a very dangerous point and it’s not going to be instantly arrested by bumping up a few more trucks here and there.

And that can speak to my second point, which – the humanitarian operations by the U.N. agencies, by MSF, by others, and the humanitarian systems are both really at a perilous point. Health sector has, for all purposes, collapsed, with some exceptions, but it’s a very small pool of hospitals still able to function, very small pool of primary cares.

And on the international operations like UNICEF, these are – these are operations – UNICEF, UNRWA, MSF, WFP, World Food Programme – these are sort of the main backbones of the humanitarian response. They find themselves paralyzed, put on the margins, security forbidding them, supplies forbidding them, the loss in security of their own personnel, as a serious constraint. And this has become existential until there is a ceasefire. And so that – they’re present, but less – not able to do – as Lana pointed out, they’re not able to do anything that truly scales to what the demand is. So we’re in that terrible situation.

The state of war since the – it’s two weeks ago that the war resumed. There’s no evidence that I’m aware of that suggests that the execution of the war, the conduct of the war, has changed. We are still seeing heavy aerial bombardment of civilian sectors, destruction of civilian infrastructure, housing, and the like. And we’re still seeing very high death rates, of which the proportionalities of women and children have not changed, despite rhetoric around those issues.

Two last points. The U.S. position has changed, at least on the surface, but it’s changed in a context in which the United States credibility has been severely damaged as we’ve moved through the Security Council vote, the U.N. General Assembly vote, and the way in which isolation has occurred with the radical swing of almost everyone behind ceasefires and other actions.

The U.S. is changing and attempting to regain ground and influence through the president, through Jake Sullivan, through the secretary of state and the like, to try and bring about less-targeted actions and greater protection of civilians and flows of key items and the easing of the siege. There’s been – the Kerem Shalom gate is supposed to be opening. We’ve seen no evidence yet that this shift of outlook and shift of approach is delivering results. I don’t want to rush to judgment to say that it won’t work, but it’s coming against a backdrop of enormous skepticism around the rhetoric or the positions translating into action.

Thank you.

Dr. Alterman: Lana, it’s a daunting picture. Could you give us a sense – Steve suggested trendlines, trendlines that seem to be moving, trendlines that don’t seem to be moving. As somebody connected to operators on the ground, what are the important trendlines you are seeing? And what are you worried about?

Ms. Wreikat: Thank you.

I want to come in on the mention of opening of Kerem Shalom, which was really welcome. But, I mean, to what extent, I mean, this will assist or facilitate aid, I mean, it might basically expedite the logistical aspects of having more additional trucks. But again, we don’t know yet.

And there are other challenges. It’s important to basically highlight that. Having more crossing points will facilitate, but then there are issues with the congestion. There are issues with the complicated logistical scanning process at the border, lack of fuel, targeting of infrastructure, looting now also.

The communities are frustrated. They’re desperate. So we’re also facing security risks for us as the situation continues to basically deteriorate. So that’s one aspect. So it’s important that we really have the right narrative. Opening Kerem Shalom will not solve our access problem and provide us with the conditions. We need more so that we’re able to operate.

And I’ll just give one example from the water-sanitation sector, where basically we lead as an organization. We delivered trucked water at the beginning of the crisis, but you were able to basically support a few hundred thousand people for a few days through water trucking. And that’s not sustainable for 2 million people, where you really need to have a sustainable, basically, solution.

The pre-crisis water supply system in Gaza was composed of three sources – three desalination plants providing 7 percent of Gaza’s water needs, water supply from Israel through the Mekorot pipeline, providing 15 percent. And then there’s the public and privately owned wells providing 70 percent of water needs. Majority of these are damaged, and you need basically to start looking at the extent of damage. We cannot do the assessment through the cluster of partners that we coordinate because of insecurity. And you need to get basically the system running so that you’re able to provide even aid.

It’s no longer about trucks getting in. It’s more really to try to be able to move and have rehabilitation for some of these critical infrastructure. We’re seeing definitely now families resorting to unsafe sources of drinking water that are highly contaminated. So we definitely need more than crossing points and more than just basically a few ad hoc solutions. It has to be sustainable, a ceasefire, and sustainable –

Dr. Alterman: OK. Lana, I want to – I want get back to water issues and infrastructure issues. We have a very tight window with Rik Peeperkorn. I’m very grateful to you, Rik, for joining us. We’ve heard a lot about the general situation. I was wondering if you could give us a sense from the perspective of the World Health Organization of what is changing quickly. What do you feel is at a tipping point? What’s the urgent message that people need to hear when people generally know that the situation in Gaza is extraordinarily difficult for civilians?

Richard Peeperkorn: Yeah. Thank you very much for having me. Can you hear me?

Dr. Alterman: Yes.

Dr. Peeperkorn: OK. So I just came back – actually, I literally just returned from more than two weeks in Gaza. And maybe, if you don’t mind, I want to – of course, as the WHO representative for the occupied Palestinian territory, I will focus a lot on health. And I want to split it up a little bit, and focus a bit on the – on the vulnerability, and focus a bit on hospital functionality, if you don’t mind, and describe a little bit also the – yeah, what I’ve observed myself in all these missions.

So since I was there more than two weeks ago, so with WHO I participated and actually – and visited – like all, we were based in Rafah. I participated in multiple missions to all hospitals in the south and one in in the north, Al Ahli Arab Hospital. And not just for assessment, but also every time for – WHO, we deliver supplies, essential medical supplies, trauma supplies, essential medicines to respected hospitals.

Now, I’m sure that you discussed already the – I don’t want to go – you can get it also from outside about the enormous amount of fatalities up till now. We talk about more than 18,000 going to 19,000 – of which estimated 7,800 children and more than 5,150 are women, talk about 60 percent – and over 50,000 injuries. So what we see is a – is a health system very much on its knees. And we have seen a decrease in hospital functionality to thought to be 20 percent. You talk about eight of the 35 hospitals were partially functional, and certainly in the south maybe one. And I really – it’s not even partly functional; that one is barely. That’s Al Ahli. And then three hospitals are minimal functional in the north. That is Shifa and Al-Awda and Assahaba, the only mother and child hospital in north.

Primary health-care centers, similar picture. Talk about less than 25 percent of the primary care centers from the – less than 18 of 72 which are functional. And our concern is also the total bed capacity gone down from 3,500 to less than – less than 1,500. Now, there is – and then, combined with bed occupancy in most hospital 200 to 300 percent what they normally have and ICU of over 250 percent. So our hospitals, I mean, like, even the ones in the south – I mean, like, the two largest ones are, for example, European Gaza Hospital and Nasser Medical Complex, and I know them very well. Normally, every month, week in Gaza we have a very strong trauma care program in Gaza, so with a team they are very operational. And, well, we really know those hospitals.

Those two hospitals I mentioned, they are limited like Shifa of the south. And if you’re walking through there in trauma wards, they’re completely overwhelmed. I mean, like, they are, like, I would say small humanitarian disaster zones – people treated on the floor, there’s no adequate treatment in many areas, a lack of supplies, and also a lack of capacity. I mean, like, there’s a lot of enormous staff needs. And the staff we saw there, they also have to focus, for example, on survival for themself and taking care of their family and getting wood, and then therefore – for cooking and the most basic things.

Now, supplies, of course, are needed. And we don’t only talk about medical supplies and trauma supplies; you talk about fuel, water, and food. And water and food I want to say for patients, but also for the – for the staff.

The protection of health care – and I think what happened in the north, that – one hospital after the other hospital became dysfunctional, can absolutely not happen in the south. And this is maybe my strongest plea. The hospital system needs to be protected. And the south is currently the backbone of the health system. So what we have to focus on, together with the hospitals, the partners, and as part of the WHO operational plan too, how can we restore them and get – can we get back from the knees? Currently, it’s almost impossible, so it’s of course supplies and equipment – and not only trauma supplies and related to that; I’m talking about essential medication, et cetera. Then, how do we focus on restoring the referral lines, the trauma pathways, the primary health care, and think about mother and child health, emergency obstetric care, noncommunicable diseases. And I don’t even want to discuss mental health, psychosocial support, so.

Now, the shrinking humanitarian space, it is very difficult, actually, to move supplies. So we don’t – when we talk about getting too few trucks and supplies into Gaza, specifically where in Gaza. And having been on a number of these missions now, let me say that they are difficult to plan. Routes change. They are often getting delays. And a couple of those missions – specifically the one to the north, for example, to Al Ahli Arab Hospital – was telling. First of all, a lot of delays because of the security issue. It was a very high-risk mission. So we had two U.N. cars and a truck full of medical supplies through that.

First of all, if you move up north, it’s IDPs everywhere. So, constantly, we have to report, like, these are medications, there’s dawa for that specific hospital, because people jump on the truck and see if there’s food or water.

Then, coming through Wadi Gaza, I’ll not go into details, but we had a lot of shelling very close by, and et cetera. We had a really nasty incident. And when we moved through Gaza City, I mean, I was really stunned by the devastation that itself is a norm in Gaza City, and I can only imagine what it must be further up north. I only – I worked seven-and-a-half years in Afghanistan. I’ve been in – in the early – in the late ’90s or the late ’80s in Afghanistan, and then the last – I’ve been here now working for three years. Seven-and-a-half years before I was working in Afghanistan. The devastation is enormous and almost like what I saw from pictures from Grozny in Chechnya or in Aleppo. There were still, to my – to our surprise, many people around coming out of their place and out of their houses, really surprised in our little convoy and actually very welcoming that we were coming up there.

Al Ahli Hospital was completely crowded. Normally it’s a hospital where there’s a bit more private sector and more – a bit more special care, but nothing of that. It’s a very small hospital and could take maybe 40 to 60 patients. At the moment, it’s operating over 200, 250 patients and it’s everywhere. It’s so called – (inaudible) – to be at that place. I think it’s now supported by the Anglican Church. Everywhere you see patients outside, on the floor, in the corridors, in every ward; in the – in the – yeah, in old wards, in the library, for example, in the church – there’s a little chapel there – and serious patients. There’s hardly any – there’s hardly any nursing care available. We know the director, so Dr. Fado (ph) we met and also Dr. Mohammed Rawan (ph), who is actually a surgeon from – who came from Indonesian Hospital, another hospital in the north, which is dysfunctional.

And because of our trauma team and our WHO surgeon – (inaudible) – so we had a quick assessment. And so there’s a lack of not only fuel, but also oxygen, which we didn’t bring, and essential medical supplies. I mean, our supplies, specifically the trauma kits, they were ripped off the truck and straight they brought to the – to the sterilization room. The lack of food and water. And health workers; for example, they lack a vascular surgeon. So, unfortunately, they have to do amputations where sometimes, you know, which should not be done and should not be needed. So we brought the supplies.

We also categorized a number of critical patients to – with the – (inaudible) – to the Palestinian Red Crescent to take 90 patients and companions out. We could have taken 30 (percent) to 40 percent of that – of the patients group. It was beyond I’ve ever seen in my life. In the north, there’s another hospital, Assahaba, and we were able to visit that as well soon. It’s the only maternal and child hospital. And Al-Shifa should start working again, because there are still a lot of people in the north and we shouldn’t forget that. The situation in the south I described a little bit.

And another issue, what I noticed, that specifically also in the – from the hospitals in the south, that they’ve tripled – like, Nasser is normally 350 beds. They have more than a thousand patients. Extra tents installed by the Ministry of Health. European Gaza are normally 350 beds; more than a thousand full with IDPs everywhere. And they also struggle to discharge patients, because patients are scared to go back where they came from because it’s unsafe. El-Najar Hospital in the south, in Rafah, is not a referral – typical referral hospital. It’s more like, I would say, a large primary health-care center. And it’s harboring more than 150 patients. Normally it has a capacity of 50, et cetera. And – no, more than 300 patients actually all coming from the north. And one – for example there, it’s the only place for dialysis in Rafah. And normally they see maybe maximum a hundred patients a day for dialysis, and then they open. Now there are more than that 350 patients when I was there.

They cannot get the four-hour shifts. They only get the two-hour shifts. A number of dialysis machines is not working. And the same story – it’s the same broken record – fuel, medical supplies, food for patients, food for staff.

Now –

Dr. Alterman: I know you have a very tight window and I don’t want to lose an opportunity if any other guests have questions for you. You have been on the ground. You do have a remarkable perspective on what’s happening.

So I don’t know if Steve or Leonard or Lana, if you have any questions for Rik about what he’s just seen or what’s happening precisely on the ground with WHO.

Dr. Morrison: I’d suggest Lana respond first, since she’s closest to all of this, and then Len and I can weigh in.

Dr. Alterman: Lana, did you have any questions for Rik, or did –

Dr. Morrison: While you’re thinking, Lana, Rik –

Ms. Wreikat: Sorry. Is it if I have questions for Richard?

Dr. Alterman: Yeah, yeah.

Ms. Wreikat: Actually, we work very closely. We have strong collaboration with WHO on the health side. And we’re part of the health cluster, and we work with them closely on nutrition and we – (inaudible, background noise). And it’s definitely all hands on deck. All U.N. agencies are facing the same. So definitely we salute WHO and other colleagues for their great efforts.

But I think what we basically – very important for all of us is basically to continue advocating to break down all operational bottlenecks and barriers for us to be able to deliver. It is a very difficult situation. I mean, we haven’t seen anything as such for years. We’re also concerned about the escalating situation in the West Bank as well – it’s not only Gaza – and of course the broader region. This crisis is going to have, really, a spillover impact, unfortunately, if the hostilities don’t stop.

Dr. Alterman: Rik, are you focused on the West Bank as well? And –

Dr. Peeperkorn: Yes. Yeah, very much so. I mean, like – and by the way, deeply concerned because I think it’s a little – it hardly gets reflected so – including in the West Bank and WHO leading and coordinating health. We already, with our partners, we are trying to pre-position supplies in warehouses but also at key hospitals, for example. I’m focusing now on the health side. And yeah, in many areas – I mean, there’s of course a huge concern about the volatility and what’s happening.

Maybe before I have to switch off, and I feel very bad for you guys because I wish I could stay a little longer. Maybe can I just highlight two things I think what should be happening and also – and very much in coordination with UNICEF, other U.N. partners, and of course the NGO. So if you look at health and if you look at – and straightaway develop kind of an operational response plan, and I want to stress the points that an operational response plan in health has to focus on the existing health system. It’s on its knees, but certainly in the south still functioning. We have to focus on the existing system. And we should not get an idea that we can fix it with a few hospitals or something like that. There’s 1,500 beds. We have to get them as quickly as possible to 2,000, two and a half thousand. What we really need is 5,000; we will not get that. We need to increase the number of beds and links to the key hospitals. We need to restore the pathways and increasing beds. So we are trying to coordinate emergency medical teams in, and some field hospitals, links, and emergency medical teams linked to those hospitals.

There’s a Jordanian field hospital close to Nasser Medical Complex. There’s a hospital from the Emirates Red Crescent in Rafah. ICRC is camping out in the European Gaza Hospital and planning for another 150 beds. And this is what we’re trying to coordinate, and that’s how we have to add beds, et cetera, and some staff.

But we shouldn’t forget, Gaza didn’t have such a bad health system. It was producing, indicates at par with its neighbor, and despite all the challenges and problems. There’s 20,000 health workers in Gaza and very good health workers. We’ve staffed – (inaudible) – specialists – for example, Hawzma (ph), who is a neurosurgeon, now traumatized everything what he experienced in Shifa. So we have to get back and make sure they can get back to work within the system.

Then the second, with UNICEF and partners we have to focus on primary health care. Not only the UNRWA, the other primary health-care centers, too. And in these huge UNRWA shelters and all this makeshift shelters, look at the basic health-care package, what you can roll out. We are very concerned about public health surveillance. Together with UNRWA, WHO we do these quick assessments, early warnings, disease preventions, and we have to focus on that – all underpinned by sustained supplies and logistics and coordination steps, plans for that, there’s flash appeal for that. There’s a need for additional flexible funding.

And lastly, we need to get evacuations within Gaza, which WHO is currently doing and helping. We need to get much more sustained evacuation outside Gaza into Egypt and to other places. It’s too ad hoc. It’s not very well-organized. And let’s not forget the long-term conditions. Before this conflict, between 50 and a hundred patients were referred from Gaza every day to East Jerusalem or the West Bank, 40 percent on quality related – children on quality, women, men. So we need to get back to something.

At the moment, I think if we would see more people displaced, and specifically from the middle area, we are heading to an even bigger humanitarian disaster which we already see. It should not have to happen. And the sensitive infrastructure, specifically health, needs to be protected. That’s my biggest – yeah, my – that’s my biggest request or plea.

I’m sorry that I have to leave you guys.

Dr. Morrison: Rik, can you just – thank you so much for joining, and your courage, and that of all of your colleagues at WHO. Dr. Tedros has shown extraordinary leadership and courage in this period, as have you and your other colleagues, and UNICEF, and the others. What is the message to the United States? What is the – what is the top-line message to people in the United States watching this particular show and wondering what should happen next and what should the U.S. be doing?

Dr. Peeperkorn: Well, of course, I think the probably the top-line message for all is it has to stop. It has to stop. I mean, there should be a sustained ceasefire. I mean, this is – I mean, there’s a humanitarian disaster unfolding in front of our eyes. And when you’re there, it’s even much worse than even what you see. And it’s not just for all the people. It’s also from your own teams and your own staff, et cetera, the stories. The toll are, yeah, uncalled for. So it’s – I mean, till when can this continue? And so it has to stop. There should be a sustained humanitarian operation, which needs to be rapidly expanded. Because in most area, we’re just scratching the surface, or not even that. Because we feel that we’re doing too little. Way too little. And –

Dr. Alterman: I think Lana would like to slip in a question before you have to go.

Dr. Peeperkorn: Yeah, please.

Dr. Alterman: Lana?

Ms. Wreikat: No, actually, I have no questions.

Dr. Alterman: No question? OK, I was misinformed. Rik, thank you very much for joining us. And thanks for all you are doing. Stay safe and best wishes to your team.

Dr. Peeperkorn: Thank you very much for having me. Bye-bye.

Dr. Alterman: Thank you.

Dr. Morrison: Bye. Thank you, Rik.

Dr. Alterman: Lana, I have a question for you. The U.S. has been focused more on this. We have David Satterfield as the humanitarian coordinator. Have you seen the U.S. making a difference on the humanitarian front? Or does it seem to be more business as usual, in your view?

Ms. Wreikat: I mean, we work with the BHA, USAID, not only in Gaza but also other countries where they provide support to our humanitarian programming and also in particular for Gaza as well. We’ve been engaging with them in relation to different sectors, and trying to facilitate aid, and unblock some of the bottlenecks we have. I think what we need to do, we need to, as U.N. really, to go back and assert the need to influence all member states. It’s not only one. There are so many member states who basically need to be brought on board to influence the two parties. Resolution 2712 is the only U.N. Security Council resolution that basically talks about a pause, a ceasefire and having humanitarian corridors.

So what we really need – we really need to make sure that this is fully implemented. And I think that’s the key message to the U.S. and to other member states as well. I think everyone, basically, has to basically pressurize parties to the conflict in this crisis.

Dr. Alterman: Thank you.

Len, I was struck that Rik talked about Grozny and Aleppo, partly because if you were to talk to Russians and Syrians, government officials, they would say, well, those worked – that’s just necessary, it’s what you have to do to win a war; the insurgency has largely ended in Syria, Chechnya is under Russian control – that this is just – war is organized violence, and one shouldn’t make apologies for it or dress it up. Does that – does that – how would you counter that, other than – I mean, how would you counter it from a utilitarian perspective rather than a moral one?

Mr. Rubenstein: Every combatant wants to win the war. They want to do what it takes by any means necessary. And that means that civilian protection is secondary or even irrelevant. And there are theories of war, including a theorist named Francis Lieber who wrote a code for the Union army in the Civil War, that basically said that the need to win a just war in particular, as Israel claims this is, overcomes any concern about civilian harm. He even said you could starve the population.

But for the last 150 years there has been a commitment to counter that around the globe, going back to 1864. That said, war is terrible, but we have to place limits on it. And the Geneva Conventions, which were the product of that thinking, have developed over that century and a half, and they’ve gotten stronger and stronger, most recently in 1977 – 50 years ago – to really strengthen civilian protection. And these conventions not only are ratified more than any other treaty in the world, but have become part of customary law. So the moral basis and the acceptance of the moral basis of civilian protection is widespread, and the idea that you do what it takes to win a war has been rejected all around the globe.

But what’s happened, of course, and what we all recognize, it’s a struggle to obtain compliance, for the reasons you said – that you want to win, and taking the utilitarian perspective you do what it takes. But we can’t abandon them. And we know that compliance makes a difference. We know that the prohibition on strategic bombing of cities has affected behavior – not of everyone, certainly not of the Syrians or Russians, but of other countries. So we have to insist on that and not use a utilitarian calculus.

And the Geneva Conventions are very explicit that the idea of military necessity to win is only permissible within the four corners of what the conventions allow. So it’s an attempt to strike a balance, but not to abandon the moral position and the legal position that incorporates it in the name of winning. But that’s, I think, what is happening here. That’s, I think, how Israel is approaching the duty of proportionality, where no amount of civilian harm, it appears, would – or expected harm would, in their view, outweigh the military advantage of destroying Hamas.

Dr. Alterman: Steve, you’ve done a documentary on civilian protection in conflict areas. How can you effectively bring international humanitarian law to bear to people in the midst of an active conflict? What are – what have you seen as the effective – the effective tools to change military behavior?

Dr. Morrison: Well, in this instance – I’d like to bring it back to this instance – something remarkable last week happened at the U.N. – after the U.N. Security Council vote. You had very respectable institutions that pay – that have expertise on international humanitarian law – MSF, Human Rights Watch, and others – step forward after the vote on Friday and say very explicitly – and this was quite shocking to me – say quite explicitly that the United States is now complicit in war crimes.

Now, if you look back, whether you agree with that judgment or not, it was a pretty sharp stick against the United States’ credibility/moral standing in this conflict. And what you have now is the United States at a very, very high level attempting to restore its credibility and positive influence on this crisis, and what do we see? We see a discussion around easing access, changing the targeting practices, and the like. Of course, the call for a ceasefire is the top element that we hear, and we’ve heard that from Rik. But what I would argue is that there are measurable – there are measurable actions that will begin that you can use in order to make judgments on whether you are getting compliance or not.

Those would be: Are there deconfliction zones and are they functioning effectively in order to try to avoid having targeting of civilian populations? Are there humanitarian corridors being put in place? Is the siege on food, fuel, medicine at the – at the border, is that being eased? And are the intensity and composition of bombs being used during the aerial campaigns changing? Those are things that we should be looking at in trying to make judgment on whether, in fact, the U.S. is complicit in war crimes in this situation. We have in our hands, and that means that we need to be able to do higher and more granular assessments of the practices on the ground.

I was encouraged that Rik was saying that we need assessments – more granular sense of the condition of the populations. My biggest fear right now is that what happened in Grozny and Mariupol and Aleppo will play itself through here, which is those excess crimes have happened and those populations reach a point where the runaway destruction is very hard to reverse. But I do think that there are measures, as I’m saying, by which we can begin to judge the actions of the parties, the Israeli Defense Force in particular in this instance.

Thank you.

Dr. Alterman: There’s an article in Israel Hayom today that argued that the U.S. had seen progress on deconfliction and some – and some of the issues. But also that the United – but Politico had an article saying the United States actually has fairly good insight into what the Israelis are doing, the U.S. is monitoring that, and while it does not want to make public judgments it seems to be something that the United States is paying attention to.

You had talked about supplies, and that’s been a theme of the problem of getting things through. But, Lana, you had started at the beginning talking about water, and of course water and access to safe water is a persistent problem in Gaza. There are some pipelines which are partly operational. What are you – what do you think is possible to ensure access to water and food? What would that look like? Kerem Shalom is not large enough, but it’s better than just having one. What would a really functioning operation for getting water and fuel and food into Gaza look like?

Ms. Wreikat: Yeah. Thank you.

I think we really need to basically have a closer look of what’s happening. I mentioned insecurities there, so we’re not able to assess the extent of damage of the water infrastructure to do repair. From our end, we were able to basically procure spare parts for the water desalination plant and infrastructure. We need chemicals, fuel, as well as spare parts. Chemicals, we have quantities pre-positioned as part of our preparedness before the hostilities started. We were able to get in spare parts. But fuel is the problem. And that was basically why we were not able to basically progress. You also have to have the water technicians, as well, feeling safe to go and resume their functions to operate either the plants or also to work on their support functions.

Health-care facilities in Gaza, as well, are also facing wash crisis with limited water supply in 35 health facilities across the Gaza Strip. So it’s putting all patients as well as people who are taking basically shelter in these hospitals at risk. For us, the wash response has been limited to provision of supplies and emergency repairs to critical sites only. And as the situation also escalated with the ground invasion, it has been really very difficult. And that’s why, again, I mean, we continue basically to call for a ceasefire, because that is basically a precondition for us to be able to move and operate.

Mr. Rubenstein: If I could add something about the U.S. role, I think that there is plenty of evidence that the administration is trying to restrain Israel in many different ways and the president spoke about indiscriminate attacks. We know there are a lot of private conversations about trying to restrain Israel’s means of war but they don’t seem to be having much of an impact.

We haven’t seen a major change in the way this war is being conducted since the ceasefire ended and we see how the ground operations are showing indifference to civilian harm, and it reminds me of the dilemma the U.S. faced with respect to supporting the Saudis in Yemen where there was a great deal of effort to have the Saudis comply with rules to avoid indiscriminate attacks – military advisors, all kinds of efforts to change Saudi behavior all the while we were supplying weapons to the Saudis and it created a great internal crisis and there’s been a lot of hand wringing since that while the efforts failed the military assistance continued and more people were killed.

And I think this is the same issue on a much larger scale, that the administration is trying to restrain the lethality of the conduct of this war. It’s not succeeding and it’s facing a major question of whether, if ever, it will say enough, we’re not going to supply these weapons with all the enormous political costs that will entail. But I think that is coming up very soon.

Dr. Alterman: And, of course, there’s also the possibility that Israel will use larger and less precise weapons. One of the arguments that the U.S. certainly put forward both in this conflict and in Yemen was that precision-guided munitions allow you to be more precise in your targeting. There’s the possibility that the United States would lose its influence over the humanitarian issues – humanitarian access issues – would lose influence over targeting and Israel would just use larger weapons because it feels it has a military need to do so.

Have you seen that in other conflicts as well? Is this is a general problem of U.S. influence?

Mr. Rubenstein: It has been, yes. When we have an ally that we’re supporting and that ally is breaching the law what the U.S. does about it and, unfortunately, the record is not that great.

And on the question of imprecise weapons, there was just an article in the Washington Post today how many of Israel’s weapons have not been precision weapons and it’s been willing to use those kinds of weapons and, of course, artillery, which is extremely imprecise, in this war.

So it’s happened before with U.S. disgruntlement in the way an ally is behaving. But I don’t think there are a lot of good examples where it has imposed the consequences that it would need to to really change behavior on the ground.

Dr. Alterman: Steve, can you think of examples where the U.S. government has really been able to shift the way a partner sees humanitarian issues? Is there a – can you think of an example where it really moved the partner’s perspective?

Dr. Morrison: I mean, not with success. As Len has pointed out, it’s – there’s been efforts; I mean, the whole deliberations with the Saudis over their bombing campaigns against the Houthis, 2015 and ’16, where is this intentional or is this just incompetence, and what do we do, and do we condition our security assistance or not. And that battle was fought on and on, and it – and it didn’t result in a major change.

I do want to – I would like to ask Lana a question and I want to make one point about what Len said on the recent bombing campaign.

The U.S. intelligence community indicated to one of the major papers that 40 to 45 percent of the bombs – of the bombs dropped thus far during 29,000 attacks in the territory – and so this is the most dense aerial bombarding campaign that’s been seen in decades – that 40 to 45 percent of these were dumb bombs and they were large bombs. So that could be changed, could and should be changed, if you care about civilians. So there are metrics, and those metrics are being generated within the U.S. government in order to equip the U.S. government, as they do their diplomacy, to be able to say this is what we have and this needs to change and be tracked and the like.

The question I’d like to ask Lana is, we know that the U.N. – the big U.N. agencies and international organizations like MSF, International Committee of the Red Cross, Save the Children, and others, they’ve all faced very, very difficult circumstances in this period. Their own people have been endangered. Their families have been endangered. They have felt aggrieved because their mission cannot be accomplished, which they pride themselves in saving lives and protecting people and sustaining people’s lives. They’ve also been riven by internal strife and rancor over the positions of their own leadership, but also the positions of how hard and early should these organizations be taking their own positions on ceasefires and the things like that.

This is a very, very difficult period, obviously, for those who work in any of these critical agencies. And I just wanted you – I realize these are sensitive matters and the like, but I just wanted you to share with us your experience and observations on how this is unfolding and how much of this does begin to impede the morale and effectiveness of these organizations that are the backbone of the international response.

Ms. Wreikat: Thank you for your question. I think the whole international humanitarian community is challenged by this crisis. We also have to look at the landscape. I mean, this comes on top of Sudan, which became forgotten although it’s a large deal and it’s escalating and getting worse every day; on top of what’s happening in West Africa in Niger and Sahel; still also eastern Africa – (inaudible) – basically where not – the war is still ongoing. So we have a number of conflicts and other natural disasters, public health emergencies – 27 countries, basically, facing cholera. So this comes on top of a complex humanitarian landscape.

But this one also is one of the emergencies that its impact also has a spillover in the region. And we saw that the majority of crises that are happening now, they’re not contained in their own border, and this makes it difficult.

I think one of the key things is the how do we basically, as a humanitarian, make sure that we continue to basically have the credibility and trust. And unfortunately, we’re seeing an erosion of trust in some of the humanitarian action because of the politicization of aid, because of misinformation on media, social media now campaigns. As you can see, they come from different directions. So definitely it is becoming really very challenging.

But from the UNICEF side, from the top level, our executive director, she was on the ground in Gaza. She visited the region. And the advocacy efforts that she has undertaken, her staff or our deputy executive director, Ted Chaiban, at the Security Council level in the General Assembly with member states private, public advocacy, I mean, these were basically substantial. And there has been, like, investment. I mentioned that we started to respond from day one, so we didn’t even wait for the Rafah border to be open. We already had pre-positioned supplies so we immediately started to respond. And I think it’s really very important that we have the narrative right on this one. But I think definitely it’s a challenge across the board, not only in the Middle East region but we are also facing the same in West Africa.

And that’s why we need to invest more in terms of having localization strategy, investing in local responders; accountability for affected populations is really critical, making sure that they’re part of the decision-making part of the discussion. From our end as UNICEF we launched our humanitarian appeal for 2024 this week, and the theme was localization. It’s basically bring the local responders on board, talk to the communities, and make sure that they’re at the forefront and center of the response so that you are able to have a very clear message not only within your organization but also to the communities you serve.

Dr. Alterman: OK. We’re going to have to leave it there. I want to thank our guests, Lana, Len, and Steve, for joining us, Rik Peeperkorn for joining us from Jerusalem. Thank you for joining us for “Gaza: The Human Toll,” and we look forward to seeing you the next time. Thank you very much.

Ms. Wreikat: Thanks a lot. Thank you very much.