One Month into the Rafah Offensive—Gaza: The Human Toll

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This transcript is from a CSIS event hosted on June 10, 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, in Washington, D.C. Today’s the 13th episode of our broadcast series Gaza: The Human Toll. It’s a product of the CSIS Bipartisan Alliance for Global Health Security, and a collaboration with my colleagues at CSIS. We’ll be joined today by Jon Alterman, senior vice president and director of the Middle East Program, which is one of our partner organizations for this broadcast; and Michelle Strucke, senior fellow and director CSIS Humanitarian Agenda, another partner for this.

We’re joined today by three guests who have kindly agreed to come back and be with us today after appearing in earlier broadcasts. We’ll be hearing from Scott Anderson, director for Gazan affairs at UNRWA, based out of inside Gaza. He’ll be coming to us from Amman. We’ll be joined by Dr. Yasser Abu-Jamei, a leading Gazan psychiatrist and head of the Gaza Community Mental Health Program. And we’ll be joined by Avril Benoît, executive director of MSF U.S., coming to us from New York.

We’ve now entered the ninth month of the war. There continue to be major efforts to try and reach some sort of grand peace plan, including President Biden’s dramatic speech a week ago last Friday. Still no resolution. Still struggles to try and bring both parties to that. We’ll hear more from our guests about what the prospects are for peace versus fighting in the coming months. We’re in week five of the new phase of escalated warfare inside Gaza. We’ll be hearing about what the consequences are for that phase, in terms of health and humanitarian programs, and the status of the population, over a million displaced, regression in the humanitarian flow.

There continues to be talk about the maritime corridor. It was off to a false start in terms of the DOD JLOTS program. It’s now back in place. No appreciable impact yet, but we’ll see what happens in the coming weeks. This weekend the Israeli Defense Force rescued four hostages. There are 116 hostages, I believe, still held inside Gaza. Among those are an estimated 43 that have passed. That rescue is now – it’s alleged was the site for over 200 civilians being killed. That captured very well the agony or essence of this war, a celebration over the recovery, the rescue of the hostages, and continued drama around civilian casualties and deaths.

Just a few blocks away from here at the White House, thousands ringed the White House on Saturday, forming a red ribbon, a red line, around the White House. Another reminder that the Gaza war has become a daily motif in Washington, whether you’re looking at it from the right, or the left, or wherever, and a daily motif in the presidential race. There continues to be a bitter standoff between the Israeli government and U.N. agencies and international bodies. Just most recent sign of that, the U.N. secretary-general announcing that the U.N. would be adding Israeli to the states that fail to protect children in war.

Today we want to turn our attention back to the health and humanitarian situation. What’s the status of the populations at risk? We’ve heard a lot about famine in the past, about the consequences of the renewed war, the consequences of renewed mass dislocation, onset of summer, and what’s the status of delivery efforts, of the operations essential to try and stabilize the populations at a high and acute risk.

So thank you all. Thank you all for joining us today. I’m going to ask Scott to open up with a few minutes of summary remarks around the state of play and then I’ll turn to Yasser Abu-Jamei and then Avril Benoît to fill things out and then we’ll have a conversation for the balance of our hour.

So, Scott, over to you. Please kick things off.

Scott Anderson: Good afternoon from Amman, and I’m very happy I can return and have the opportunity to speak with everybody today.

So let me just set the stage for Rafah if we look back a little bit in time. On May 5th there were 1.4 (million), 1.5 million people in Rafah that had been displaced, most of them multiple times, from areas across Rafah, from those as far north as Beit Hanoun to people just in Khan Younis.

The evening of May 5th it was reported that Hamas had agreed to a ceasefire deal. I remember hearing celebratory fireworks, gunfire outside the guest house where we stayed in Rafah, and then come May 6th, unfortunately, we found that was not true. Evacuation orders were issued for parts of Rafah and the operation, preparation, and implementation that the IDF was going to move into Rafah had all began.

So we went – since that time of having 1.5 million people in Rafah that were displaced we’re down today to somewhere in the neighborhood of 85,000 people are left. So all those people – 1.49 million people – have again moved. Most people displaced this is their seventh, eighth, and ninth time. When you talk to people they tell you the first and the second displacement are the hardest, the first because you’re leaving your home and the second because they thought they would be going home.

But, unfortunately, they’ve had to continue to move to try to find safety for them and their family in what is a very dangerous environment and location in Gaza where there is nowhere that is truly safe because we continue to see things happen that impact innocent civilians like the Operation Nuseirat. Very happy the hostages are being released but reportedly the cost of that rescue is quite high in terms of human life and we wish it could come through negotiation and at, you know, no more cost to human life.

The other thing that Rafah has done is it’s disrupted what was already a fragile aid operation for the international humanitarian community. Our main source of aid comes through Egypt in through Kerem Shalom. The vast bulk of all aid is in Egypt. At one point we had 80,000 metric tons of aid in Egypt, 180,000 metric tons on the way.

When the operation started in earnest May 7th we were not able to access Kerem Shalom for a few days and our access since then has been very hit and miss and it’s kind of ebbed and flowed as we’ve tried to – you know, to move aid in.

Before the conflict, we were getting 300-plus trucks in every day, which is, you know, what we need at a minimum to sustain the population south of Wadi Gaza. And since then, if we can get a hundred trucks we’re doing well.

Now, this will not sustain the population. It does concern us greatly our ability to access Kerem Shalom is really – whether or not we can access Kerem Shalom is going to determine whether or not we can respond adequately to the displaced population across Gaza.

You know, south of Wadi Gaza there’s, give or take, 1.8 (million), 1.9 million people that have all been displaced at this point. They’ve been displaced to a very small part of Gaza in parts of Khan Younis, part of the middle area near Deir al-Balah and Nuseirat, and, unfortunately, where they’re displaced there’s not a great deal of infrastructure.

There’s, certainly, no water network. There’s no sewage network. The road networks aren’t great and all that impacts our ability to get people what they need just for their – you know, their daily lives, their basic necessities.

This entire conflict we have not been able to get any – enough stuff in to take care of the needs of women. There’s no sanitary pads. There’s no other hygiene kits for women to take care of themselves and women have very much borne the brunt of this, and as we look at the impact Rafah has had on this it’s just made what was already a very dire situation much worse.

So – and I guess in sort of a very odd twist of fate, people in the north of Gaza – where we were very concerned about famine just a couple months ago – are now in better shape than people south of Gaza in terms of their ability to access aid. And that’s because we finally have had a crossing from the north to the north and we’ve been able to import aid at a much greater scale for people. And while I wouldn’t say we’re completely out of the woods in averting famine, we’ve certainly made significant headway to try to keep that from happening.

And just as a – I guess contextually, the first half of May we had more aid into the north than we did all of March and April combined, which is a great achievement and it certainly, you know, steps in the right direction. But just getting aid or food in is not sufficient. It has to be the right aid, the right quantity, the right quality. So we need food, medicine, water, and fuel.

Our entire operation starts with fuel. It’s the lifeblood of the response. And our fuel was coming through Rafah from Egypt, and now it comes through Kerem Shalom. And it makes – again, makes it very difficult for us to bring fuel in to sustain the operation. We need a minimum of 200,000 liters of diesel a day. At one point, we were getting about 60(,000) to 70,000. And that forces us to make very difficult choices around what do you make sure keeps running – generators for hospitals, generators for bakeries, generators for sewage, trucks for solid waste, trucks for the aid operation? And not doing any of those, they’re all terrible choices, and they have consequences for human beings on the ground in Gaza, for innocent civilians. So we need to make sure we have access to fuel, which has increased but remains a concern, because it drives everything else that we do.

And the other thing to highlight is it is becoming summer. It’s very hot in Gaza. We basically live in a desert. It’s on the Mediterranean, so even though it’s desert-like it’s also very humid. It’s very hot, and people are in tents. They have no way to cool themselves. They were accessing about 5 percent of the clean drinking water they need every day. And that is not something that’s sustainable, as the temperature’s only going to increase between now and the end of August. So the people that are most vulnerable – children, the elderly, those with chronic diseases – they’re all going to face great difficulty in making sure that they’re cool, not impacted by the heat.

So as we, you know, move forward in time, we’re very, very concerned about our ability to get water to people. We’re very grateful that we do now have the crossing in the north. The maritime corridor has functioned, not at the scale that we would like to see. We do see that as very additive and certainly not as a replacement for any other streams of aid coming into Gaza. And as I said previously, our number-one way to bring aid into Gaza is through Kerem Shalom, and we need to have sustained and continuous access to make that happen.

So I’ll close by saying that you now have 2.2 million people in Gaza, all of whom have been displaced, all of whom are traumatized, all of whom either have lost or had a family member injured, be they immediate family or distant family. And it’s a population that after nine months of conflict is very much praying for a ceasefire so they can begin to rebuild their lives and try to make a better future for themselves and their family. Thank you.

Dr. Morrison: Thank you, Scott. Thank you so much for that briefing, and for your service and continued leadership in this domain.

I’m going to turn to Dr. Yasser Abu-Jamei to help us understand the mental health dimension of this. Thank you for making the time, Yasser, to be with us today. Over to you.

Yasser Abu-Jamei: Thank you very much. And hello, everyone.

I’d really like to continue on what Scott was saying. He gave a very brief and comprehensive idea about the living conditions in Gaza Strip for the last nine months or eight months and – (inaudible) – what happened during May and perhaps June already.

Let’s keep in our mind that all the time when we talk as mental health professionals about the mental health conditions of the population in Gaza Strip, we talk about multiple repetitive exposure to traumatic events. This is something that is happening for decades now, and it got intensified for the last maybe 17 years since the first large-scale military operations in 2008, so on, until now, what’s happening since October the 7th. And all the time we talk about how the exposure to the traumatic event really impacted the population, and maybe to highlight a little bit about children, the very recent – but not that recent, actually – report by Save the Children – that was in, I think, August of 2022 – spoke about eight out of 10 children were really emotionally distressed, and about two-thirds of the caregivers, they feel not capable of helping or supporting their families or their children. So we speak about already 80 percent of the children population and two-thirds of Gaza’s population were facing physical and emotional distress. And that was already a year and a half before October the 7th.

Now, the difference this time is, first, the multiple, repetitive traumatic events are happening within a very short time scale. We speak about only seven to eight or nine months, when people who are, again, exposed – not only exposed to multiple traumatic events, but also they had to flee their houses. Some of them were pulled from underneath rubble more than once. And some of them definitely endured someone who was killed or injured from his maybe nuclear family or extended family. We speak about 100,000 people who were either killed or injured. And we know that in Gaza Strip the populations are 2.3 million people, maybe 400,000 families. So almost, as Scott said, everyone has a member of his extended family at least who got injured or got killed.

And you add to the exposure to the traumatic event a very important factor, which is the resources and the level of exposure. Of course, when you are hearing the bombing every day and night continuously, the fear that the end is here, it’s nearby, it could be at any moment, that continues forever over the last eight months. When you have in mind the resources that are decreasing, and decreasing, and decreasing, and almost not available – (inaudible) – we are speaking about famine for the first time perhaps in the – in the recent history, speaking about Palestinian people being exposed to famine. So you speak about multiple, again, repetitive traumatic factors/events, and at the same time decreasing over time resources that could help people survive those traumatic events.

And then when we speak about the mental health impact, we see that the people are severely impacted by those conditions. However, at the same time, at the moment a lot of science of that emotional or that psychological impact are not yet done. This is something that we have – we have noticed really – (inaudible) – ceasefire that takes place, people start to look at what happened to their lives, people start to think what we can do next, how we can recover, how our family can function back, what we can do with our children, and then – (inaudible) – the environment and how they can improve things.

At the moment, most of the people, I would say, especially the adult population, are somehow in, we could say, survival mode. One of – for example, one of the cases is a young lady who is just a 23-year-old. She was pulled from the rubble into the intensive care unit – all family members were killed. Her parents were killed, her brothers and sisters were all killed, and even some of her nephews were killed in that. Anyone who was there in the building got killed, and she was the only survivor. And she was in the intensive-care unit for many days because she had sustained some head injuries.

Now she is out of the intensive-care unit, and she spends time – (inaudible) – between one hand into the other hand, you know, because she feels that she is a burden to the community. But at the moment, you know, what she is really thinking of more is where can I find, really, treatment, because being injured means that you endure not only the difficulty of being injured, but the question is whether I could find treatment one way or the other. And historically over the last 10 or 14 years, a lot of the difficulties that we faced and that we saw in injured people is that pain and the pain management, and the lack of adequate health support to those injured people.

So now her main focus is: How could I really get treatment? For example, how could I find a good hospital that would care? How can I leave Gaza Strip to find some kind of support? So that’s what really occupies her mind. But I think in a different moment in time, when that – when she really improves physically, then her memories will come back. And then she will start thinking about her beloved ones, about her parents and – (inaudible). On the other hand, the way that people mourn is extremely alarming and very strange. You know, one of the ladies who was originally from – that young one was from Gaza City, really early, and she was displaced in Rafah. And now she is displaced back to the middle areas. I am not sure where is she at the moment, within the last couple of days.

Another lady who was, like, in her forties, you know, she was talking to the trauma – (inaudible) – because her son got killed. She was also pulled from the rubble with her family. Only one person got killed. And the injury was to his abdomen – (inaudible). And she says, you know, his guts were out. You know, his spine were out. The injury was severe. You couldn’t really rescue him. Nothing would work. But – (inaudible) – thank God, that we managed to bring him. You know, we managed to bring him because, of course, she knows that there are thousands are people who are still below the rubble.

And the issue of mourning the lost ones is a big issue in Gaza still. It was historically something big that – it’s big for everyone. But again, to – I mean, everywhere in the world, you know, for someone to pass away or to die, it’s a very long process. It’s a very complicated process. Even if you die – you know, if you are killed, also, it’s a very complicated process. It’s not something easy that happens in a moment, you know? But in Gaza, that’s not the case, you know?

So people are not thinking about what they can do when somebody gets killed, I mean, at the moment. Can we really revive the – but in order to offer our beloved ones the dignity that they deserve, at least to have died to a good burial, you know, in a good cemetery, or something like that. But unfortunately, most of the people don’t have that.

And to end up with, it’s really how – people compare what happens to them. It’s very interesting. You know, I was with some of the Gazans. There was one who got his in-laws killed, you know, and their children. And these were two brothers who were, like, 17 and 12, and they were killed of attacking one of the buildings, you know. So they were pulled from the rubble, of course dead. And then we went to hospital for the burial, and et cetera, et cetera.

Then I saw someone else. And what he was telling me, too, was really interesting. He said, you know, doctor, it’s sad, but it’s also at least they managed to see their children before they bury them and they offer their burial. In my case, my son was also a young boy who was 15, you know. He got killed in east Khan Younis, and we couldn’t really reach him. And the only way that he got buried is that he was pulled from the street and buried in one of the shelters, which is a school, you know. He was feeling so much pain that he didn’t really have the time or the chance to just say goodbye to his son.

And so the conditions are really staggering. The level of atrocities are unprecedented. The level of destruction is really unprecedented. And the pain that people are going through are unprecedented. And I think that now the most word that people say is that we are tired and we are frustrated. When should this end? Isn’t that enough already? And this is the general feeling among the population. But we can talk a little bit later. Thank you very much.

Dr. Morrison: Thank you. Thank you so much, Yasser. And thank you for your remarkable work. I do hope in the course of the conversation we hear a bit more about what you have been able to do. I know the psychiatric hospital was damaged and shut very early in the war. You have eight programmatic clinics, centers, as I recall, that are under your jurisdiction. And it would be good to hear more about what has been possible in this period to provide support. You had a fairly significant network and infrastructure pre-October 7th. And so we’ll come back to that.

Avril, thank you so much for being with us today. Over to you.

Avril Benoît: Thanks very much. It’s really harrowing to hear all these stories. And maybe what I can do is focus on the – on the horrific situation in the hospitals, and the impossibility of providing good medical care under these circumstances.

As you may know, we’re supporting a number of health infrastructures. Over time we’ve seen one by one the orders to evacuate, and then the destruction of health facilities. So 13 different times it’s happened to Doctors Without Borders, or Médecins Sans Frontières, MSF. And these incidents then that follow the evacuation order, if there is forewarning that is usually too brief, involve airstrikes damaging the hospitals, ground offensive right into the medical centers, destruction of medical property, including gauze thrown on the floor, you name it.

We received an update from Nasser Hospital, which is one of the hospitals that we continue to try to support. We rehabilitated it, actually, after having been forced to evacuate with the militarization of the hospital by the IDF, and then – and then put it back together to try to function. And it’s been very, very busy over the last little while.

So over the weekend, of course, with these attacks in the middle area, the hospital did receive a bit of warning that they could expect a lot of wounded because they heard the airstrikes, they heard the fighting going on just to the north of them, but very quickly they became completely overwhelmed. Within one hour they received 50 patients. And the patients just kept coming in, making it absolutely impossible to do a triage in the normal way where you’re dividing patients according to their likelihood to survive. We had open fractures of limbs, shrapnel wounds, traumatic abdominal injuries, unconscious children requiring CT scans, and limited capacity to give that for the number of patients needing it, a lot of amputations required, eviscerations, traumatic brain injuries, a lot of bad burns which require long-term follow-up care to prevent death from infection, patients who required chest-tube insertions for major injuries to the chest. The operating rooms were just running nonstop, flat out, despite some limited resources, including a lack of morphine, ketamine, just generally speaking not enough painkillers. And meanwhile, you’ve got expectant mothers who need urgent cesarian sections right in the middle of all of this.

Over at the Al Aqsa Hospital, which is not too far away, the director of the hospital called out team after they received a mass-casualty influx, and so three of the members of our team went over there to try to help as much as they could. They grabbed supplies, stuffed their pockets, and walked into a very difficult situation after an unsafe journey. They had to really calibrate when they could make the movement to the hospital. And what they found there was absolutely shocking, with mayhem in the hospital compound as people were rushing trying to bring in the wounded. Inside the hospital, they described total chaos with the red zone, the yellow zone, the green zone completely packed with patients; patients on the floor; more coming in all the time. And they did whatever they could to stabilize some of the patients – IV fluids, splints, bandages, referring some to surgery. But of course, along with the wounded you had dead bodies brought in plastic bags, wrapped in blankets. And so it’s absolutely horrifying.

And when you hear those descriptions, of course, with it you have the numbers, with an estimated 83,000 injuries. And of course, some people cannot make it to a health facility because it’s too dangerous to move, and so we don’t know the consequences of their injuries. But 83,000 that have been counted. An estimated 14,000 now are on the list requiring medical evacuation, and we figure that that number will no doubt increase because the diminishing capacity of hospitals to even patch people up on a very basic level just keeps being a factor.

We’ve had a lot of attacks on health care, amounting to almost 500 health-care workers killed, including doctors, nurses, paramedics, pharmacists, and lab staff, which makes it very difficult to continue without all these people that are desperately needed. And for us at MSF, of course, we denounce this destruction and disruption of the health-care system. It’s an essential infrastructure. It’s a civilian infrastructure for the survival of the population.

And just to take a look quickly at the situation overall, you know, despite our staff responding increasingly to these mass-casualty events – which is essentially when the normal hospital services of a busy hospital become overflowing – these are happening in an unstable environment where even coming and going from the hospital is not safe with all the high insecurity. And so in the end, what we can say is that we don’t have enough hospital beds to meet the needs. We don’t have enough supplies.

Just as a little footnote, we’ve really struggled since the closure of the Rafah border crossing with supplies. We have trucks waiting with supplies. Even if one arrives in with some tents, it’s never quite sure that it will reach its destination to be able to set up the tent. There’s a lot of pressure on us to build field hospitals, and notionally speaking the field hospital gets approved by the Israeli authorities, but then you don’t get the approval to bring in the supplies necessary to actually set up and equip the field hospital. So it’s all, you know, an instrumentalization of aid to make it look good on paper and then blame the aid community for not being able to meet the needs. For importation, the problems with supplies continue and we don’t always know when we’ll be able to restock. So, obviously, field hospitals are needed now, even if they cannot fully replace the hospitals that are destroyed. And we cannot run hospitals without supplies.

So the overall ask continues to be, I think, for many of us and many of the organizations on the ground for an immediate and sustained ceasefire with the entrance of meaningful humanitarian aid. And until we get that, we will continue to see people die unnecessarily. Thank you.

Dr. Morrison: Thank you.

We’re going to hear from my colleagues Michelle and Jon momentarily. I do want to raise for you to consider when we get back into the conversation here this question around the two parties to this war. This is an escalated – phase of escalated fighting. There’s been, obviously, several recent episodes where there’s been condemnation of IDF striking civilian sites. There’s also been parallel allegations that Hamas is embedding and using sites to its benefit. And we’ve seen this back and forth, cross-cutting allegations when the UNRWA settlement site was hit, when some of the hospitals have been hit, and the like. That contestation continues in the – in the airwaves around this war and who bears responsibility, and it would be good to get your reflections on that.

There’s been a lot of discussion around creating some more effective deconfliction mechanisms. It would be good to know whether such have been put in place where communications between those who are – those humanitarians who are attempting to navigate this very dangerous security situation are able to communicate better with the IDF in this period in time. Those are just two big issues that I’d like to put out.

Michelle and Jon, if you could sort of respond to what we’ve heard here today with some brief remarks to get the – get the ball rolling in this conversation.

Michelle Strucke: Thank you. Thank you, Stephen. Thank you. Thank you to our colleagues joining us today under such dire conditions.

I think I can’t help but be moved when I hear how bad the situation has gotten. I mean, it’s already starting from a baseline of – a context that this whole siege and lack of access for humanitarian aid is not normal. This is not what we see in other contexts. We’ve heard that over and over again since this – since October 7th and since the operation started in Gaza, that humanitarian law is not being respected in the way that it should be. And that – you know, the conditions right now, if you look at statistics, 80 percent of commercial buildings have been destroyed. That is, basically, the majority of commercial civilian infrastructure. Six hundred twenty-five thousand students with no access to education. Over 96 percent of women and children aged six to 23 months are not meeting their nutrient requirements. Basically, every woman and child that needs nutrients to feed a baby is not – is malnourished. And just the scale is really incredible.

The fact that border crossings are closed means that the last month the escalations in Rafah have caused, basically, catastrophe. And just I wanted to point out and highlight what colleagues said about, you know, two themes.

One is these terrible choices that humanitarians have to make. And humanitarians are no stranger to terrible choices. In contexts all around the world, they have unfunded, you know, mandates and unfunded humanitarian responses where they have to make difficult choices. But this situation is really unprecedented, the fact that people are themselves essentially victims and displaced and are still trying to deliver aid. Aid workers themselves have had their family members die or at risk of malnutrition, and are still showing up to work to deliver this kind of aid. It’s really – it’s such a(n) angering situation that I see humanitarians being put in. They’re taking on the majority of the risk, especially local aid workers, and yet they’re still being asked to stand up and deliver.

And then drawing on what Avril said, the idea that authorities that are in charge of approving access, approving aid deliveries, convoys, and border crossings openings are making things essentially look good on paper but then blaming the humanitarian community that’s a point that’s worth restating because humanitarians are doing everything that they can on the ground and more, more than they should ever be asked to do by the governments that are funding them including the United States government and yet they’re being blamed for aid not reaching populations when they don’t have the safe unfettered, unhindered access that they are guaranteed as a minimum under humanitarian law.

So this is really striking, and another point to emphasize is this idea that – I think a lot of us have seen over the weekend the images that have come out. We’ve been watching images from Gaza coming out since the beginning but images of, you know, people holding their, you know, three-year-old dead child in their arms just trying to say goodbye, I mean, it’s something that – we are the country

in the U.S. that exports the most violent media in the world for our own, you know, entertainment purposes and yet images like these are things that our general public are not seeing and from what I understand in Israel a lot of Israeli society are not looking at either when they think about the human toll.

So, to me, I think it’s really concerning that given how bad the situation is we don’t see robust enough action happening from governments that could be taking a stronger role. So the ceasefire proposal is still on the table. That’s really important.

But there are, you know, other leverage tools that the U.S. could be using, for example, that they haven’t done in a strong enough way and that’s where that red line comes in.

Dr. Morrison: Thank you.


Jon B. Alterman: You know, Avril talked about the instrumentalization of aid. It seems to me there’s been an instrumentalization of suffering on both sides in this conflict. Hamas benefits, in its own mind, from human suffering.

You talked about more than 200 civilians killed in the raid. Actually, I’ve never seen a number through this whole conflict of civilians killed. Hamas sees every death as martyrdom which helps build solidarity for this struggle – the arms struggle that Hamas sees itself in and which it’s committed to.

So from a Hamas perspective the advantage of Palestinian deaths is it not only draws Palestinians together and builds Palestinian solidarity and commitment to the struggle but it undermines Israel in the world. In the Arab world it undermines all normalization efforts. It helps undermine support for Israel in the United States.

That’s one piece, right. And on the Israeli side the Israelis are profoundly indifferent to Palestinian civilians’ suffering because they think that if there’s enough suffering the Palestinian population will either flip against Hamas or will decide that fighting back is futile and they’ll stop fighting.

And so what I find really painful about all these presentations, right, is you have an aid community which is genuinely, genuinely committed to saving human lives, to defending innocence, to dealing with the profound trauma that millions of Palestinians not only feel now but have been feeling for decades, and you have people who are risking their lives to address that and you have combatants who say, we’ll get to that later but there’s some fighting that needs to be done now.

And what I find really troubling is that it looks to me, especially after last weekend, each side thought they had a good weekend. Israel said, we showed that we can rescue people. We showed that we’re powerful. We brought solidarity. We brought hope to Israelis. We’re resolving this horrible hostage crisis with Israelis who were being held hostage and rarely visited by the Red Cross or anything else.

And Hamas says, look, the Israelis took a beating. Look at how many Palestinians were killed. They created this ring of fire. And we showed we’re not giving up. And what bothers me most is rather than following President Biden’s proposal of saying we’re going to explore a ceasefire, get hostages, prisoners released, more playing the long game. Neither one really has a long game, and the short game is more people are going to suffer.

Dr. Morrison: Thank you.

These are both very eloquent, succinct sort of big points. I’m going to come back – Yasser, I’d like you to respond to what we’ve just heard about the way in which the civilians are caught in a situation where the two – the two battling parties are, as Jon explained, not exactly taking their own human interests in mind. Your thoughts?

Dr. Abu-Jamei: Since the very first days we were thinking all the time at GCMHP what can we do in order to help the population, you know. And we have something that is called crisis response plan that we activate whenever there is – (inaudible) – or something that is causing a lot of increase on the psychological impact on the population. Since day one we thought of keeping at least four types of interventions.

One is to provide – (inaudible) – first aid to the most needy people, and this happens through groups. Psychologists, usually a man and a woman, they go with us to visit the families in the – (inaudible ) – house, in the schools, at the tents, et cetera, et cetera.

The second one is to try to offer counseling to those affected people. And part of it is to offer telephone counseling, a toll-free line.

The third one is to continue to offer the therapeutic interventions, because we the only nongovernment organization that offers comprehensive mental health interventions. That includes psychotherapy and medication.

And the fourth one is all the time to care for the caregivers or the helpers.

So in our mind was all the time the question not only how – the knowhow is something that we know already for decades at GCMHP – but also where and when. And that’s why, you know, it was obvious since the first month that only a sense that, first, the need to intensify our we had to anticipate our work in the southern areas of Gaza Strip. Most of the people of Gaza, in October they fled to Khan Younis and to Rafah. And from December, most of the people fled to – from Khan Younis also to Rafah.

So by the beginning of the year of 2024, there were more than 1.5 million people already in the area. And that’s why we started to try to operate from Rafah. And we managed together ourselves, you know, because also most of our staff were displaced and many of whom were in Rafah, and we started to operate from the – (inaudible) – building on what we have, you know.

And imagine you have a population of 1.5 million people in that very small geographical area; more than 1.2 million of them are living either in tents or in schools. A school that is equipped to just receive 500 children a day during class studies, now it has more than 3,000, 4,000, and sometimes 5,000 people who are taking haven in those schools.

However, what happened, really, when the attacks on Rafah began is that those 1.5 million people, including our staff, had to flee the Rafah area. So it’s like you were displaced to a place that was announced to be, like, safe for them, and suddenly out of – like, within two or three days things flipped from, like, being a safe area to a place that you need to really evacuate. And that intensified extremely suffering of the people. Some of the people who managed to get some basic needs collected and gathered, like a small tent or something like that, they lost it again and again and again.

So what happened is that the – with the time that is possible, with the more displacement that is taking place, the suffering of the population is extremely deep. And the ability of service providers to continue providing the services that is already challenging is becoming more and more challenging.

At the moment, you know, we lost our place in – a permanent place in Rafah. Our permanent place in Khan Younis is also lost. We are trying to help our staff reach their areas through means of transportation. Transportation is a very big difficulty. So, I mean, it’s not – we are not in a status that it’s not only causing pain to the population, it’s not only causing suffering, it’s not only killing the population; but at the same time, hindering the recovery, not allowing efforts to help the population at any – in any ways or with any means.

Even those who’ve had to return to their places, they couldn’t really return to Gaza in the north. Most of the people who were living in Khan Younis, they returned to some places in Khan Younis that are not announced safe yet. And this is for a very simple reason, that there is a strong belief that there is no place that’s really safe. Whether it’s announced safe or not safe, it’s still a place that could be severely targeted. And what happened in those inside of Rafah a couple of weeks ago, when the tents were buried with people in the tents, you know, because of the – of the bombing, sent a very clear message to the people that it’s not only no place safe, but even the announced safe places could be places that were targeted. And that caused a lot of frustration, a lot of despair.

And then the question is, what do people expect in the future from this? We used to tell – for many years ago, you know, and we continue to say that, you know, the end of the human suffering doesn’t come out of just reaching the ceasefire, you know; you need to solve the root cause of the problem. I mean, no one should expect any population to continue to live in peace with an occupation. It doesn’t work like that. And what happen to the Palestinian right now is that, you know, it’s either to weigh a solution or instead of solution that we are going to continue until the end to keep this fight, because we are entitled as human beings to have our own place, to have our own government, our own freedom to live in dignity, to live at peace, et cetera, et cetera, et cetera. And what is clearly seen by the international community, that this is not on the table at the moment.

So this very negative, I would say, indications that are reached to the – that reach the Palestinian community is really deepening the suffering. It’s making people more or less pessimistic. There is a problem with – all the time we say this is very important to find windows of hope that the future will be a better one. But at the moment, unfortunately, unless the international community acts soon, and very soon, these, like, windows of hope will not be there at all.

Dr. Morrison: Thank you. Thank you very much.

I mean, in listening to the three of you and the remarks from Michelle and Jon, we’ve entered a period of intensified fighting. It could go on for quite a while. The humanitarian operations have suffered additional regression. And it’s not clear to me that there’s a pathway towards recover in the midst of this intensified fighting.

We do have a gathering in Amman for one day called by the king. I don’t know if that offers some hope of refocusing international attention. But let’s go to Scott and Avril. What – am I characterizing things correctly, or has there – is there more – is there some positive movement that you can point to? And what is it that – what are your – short of a ceasefire – if we don’t have a ceasefire, what is it that you’re pressing for right now? Scott?

Mr. Anderson: (Off mic.)

Dr. Morrison: We can’t hear you, Scott.

Mr. Anderson: (Off mic.)

Can you hear me? Is this better?

Dr. Morrison: Yeah. We can hear you now.

Mr. Anderson: OK. Not sure – apologies for that.

I was going to say, unfortunately, you have characterized it correctly. It’s a very dark time right now in Gaza. It kind of reminds me of when I got here last November, when we were unable to get anything in in terms of aid. I think the deconfliction process – and you spoke of this a little bit earlier – has also taken a bit of a step backwards. You know, over the course of this conflict over 200 humanitarians have lost their lives. World Central Kitchen, that was a very tragic event; a UNDSS colleague lost their life on missions that were coordinated. And I think just this last couple weeks we’ve had deconflicted sites for the World Food Programme hit. We’ve had other deconflicted sites that have suffered shrapnel and other damage. You know, so it’s a very – a very difficult time.

We are all very committed to being here, to saving lives. But to do that, we do need access to aid. We all want to stay and deliver. But we can’t just stay; we also have to deliver. To deliver, we have to have access to what is needed.

Now, the other thing I’d like to point out, just to make sure everybody understands that’s listening, is for people in Gaza there is nowhere to flee. It’s a very small stretch of land 42 kilometers long, 11 kilometers wide. Their ability to move away from conflict is very limited. And that also plays a role in their mental outlook because it’s a constant pressure, it’s a constant fear for yourself, for your family that you aren’t anywhere safe. It’s not like what’s happening in Ukraine – which is equally horrible, but there people can move farther and farther away from conflict. Here, the farthest you’re going to move is maybe a kilometer or two and hope that that’s safe.

The last thing I’d like to mention on this that I think would be helpful to all of us is there is no international media in Gaza to report on what’s happening. You have some local stringers or local reporters, but they don’t carry, unfortunately, the same level of confidence that people have in listening. And what we do need is media here to tell the story of what is happening to people, to the innocent civilians, and I think that could make a positive difference for how the conflict is viewed.

Dr. Morrison: Thank you.


Ms. Benoît: I would just add that, you know, this consistent justification for attacks on civilians and civilian infrastructure, such as hospitals specifically, is so unhinged, if I can – (laughs) – use the diplomatic word. I mean, what do you imagine medical personnel in a hospital that is barely functioning, that has parts of it that are not functioning at all, closed off, what do you expect them to do with such heavy militarization of the whole area? They can barely bring patients in. There are perhaps activities going on underground in tunnels either by Hamas or other militants or IDF operations, armed people who are ready to shoot on sight. Do you expect the medical officials – the doctors, the nurses – to run down there with syringes and scalpels and ask them to leave so that the hospital doesn’t get attacked, or to go in a part of the hospital that is partly damaged, closed off because nonfunctional? Do you expect them to have that control over the entire space?

Under international humanitarian law, civilian spaces and civilians themselves are to be protected despite the military objectives on both sides. And it’s one of the reasons that, you know, all the belligerents in this conflict need to respect that. And of course we don’t want the hospitals to be attacked, but systematically one by one they are being attacked, and it’s being justified on these very flimsy and, frankly, shocking grounds. And I would expect that the U.S. government and all governments just abide by and respect international humanitarian law. Even U.S. laws – the laws and protections in place are fit for purpose, but they need to be respected.

And you know, just as a concluding remark, you know, all states that are supporting Israel in these circumstances or Hamas or other militants are morally and politically complicit for harms that come to civilians for sure. And we call on all states – in particular the U.S., the U.K., EU member states – to do everything in their power to influence and stop supporting this ongoing siege and the continuing attacks against civilians and civilian infrastructures in Gaza. The war has to stop.

Dr. Morrison: Scott, can we expect anything good to come out of this Amman gathering that the king is calling?

Mr. Anderson: I mean, there’s certainly a high level of participation. The delegations are at a very senior level. The king’s coming, President Sisi is coming from Egypt, Secretary Blinken, just to name a few. We are going to talk about how aid gets into Gaza and then how it’s distributed when it’s in Gaza. And they’re also going to have a talk about early recovery, which does give me hope that people are thinking of that, what comes after the ceasefire.

You know, it’s going to take a long time to rebuild Gaza, but we need to start looking at early recovery. How do we repair the infrastructure? And to me most importantly, how do we get children back in education? Between COVID and this conflict, we’re looking at a lost generation of children – not just the lost education opportunity, but the routine is needed for children: going to school, making friends, learning, growing. It’s all part of becoming a functioning adult. And the sooner we can start that process and to begin healing the trauma that people have experienced, the better. So I very much hope that’s what we’ll get out of it, at least a(n) early look at early recovery, and see what we can do to begin planning for what we hope is a ceasefire very soon.

Dr. Morrison: Thank you.

We’ve got a few minutes remaining. I want to come back to Jon and Michelle for their thoughts. Just to put on the table for our closing, I’d like you each to – when get to closing in a few minutes, just tell us what your topline message or messages would be for a Washington audience. We’re, obviously, reaching beyond Washington, but most of the people who tune in are focused on what the United States should be doing in this period. Much of our debate has been about red lines and conditionality around military assistance. That debate has gotten a little bit – a little bit convoluted at times. But we’re talking here today about some very concrete demands, and it would be good to circle back. But, Jon, I want to hear your thoughts, and then Michelle. Jon?

Dr. Alterman: I mean, I agree with much of what Scott said. I think it’s important to understand this is also Hamas’ gameplan. It’s not the Israeli military’s gameplan, but it’s certainly the Israeli political leadership’s gameplan. It’s Hamas’ gameplan. And then the question becomes, what can the U.S. do to move toward some other outcome? I am not sure everything that went into the president’s decision to float this ceasefire idea, although it does seem to me the president was partly

trying to jam Prime Minister Netanyahu but partly also to put more burden on Hamas. There were a whole set of U.S. diplomatic calls to try to get Arab states to pressure Hamas.

Part of the problem, frankly, is Yahya Sinwar who has opposed agreements with the Israelis. He opposed the agreement that released him from jail because he thought fighting was so important. And I think we have to understand that, squarely, this war is a decision by Yahya Sinwar and Hamas. There is a desire not only to fight, but to suffer – not because they’re going to win this battle, because they see it as laying the groundwork for winning a larger war.

Dr. Yasser spoke movingly about the desire to have self-determination, and all those kinds of things which Palestinians absolutely need. But I haven’t Hamas talking about Israeli and Palestinian self-determination. And I think – I’m afraid that for all the suffering we’re seeing, the combatants on each side – especially Hamas – sees a utility is more suffering. Not because they think it’s going to save any lives now. The humanitarians’ job is to save lives. Their job is to win the war. They’re making the sacrifices. They’re lining up more martyrs. They’re building more solidarity. And I think that’s a recipe for more tragedy.

Dr. Morrison: Michelle?

Ms. Struke: We’ve heard compelling, you know, statements here about the indignity in this conflict, the indignity of what civilians are facing, what humanitarians are facing. Even the basic dignity of the dead that is not being respected. And my concerns, forward-looking for policymakers and for a Washington audience, are twofold.

One is this idea of what will be left. What kind of population is left, whose children have been denied their futures? Where, you know, one in 23 Palestinians have died. Where the, you know, education, health-care system are eroded, where we’re expecting to see disease be rampant. You know, what kind of future is really left here? And how – you know, I’m glad that the Amman Conference is starting to talk about early recovery, because putting support into building that future once this ends is really important. And nothing can deny how important it is to have a ceasefire accepted.

But my next concern is really, with all of the IHL violations, with even the State Department and the White House in their report discussing the fact that humanitarian law has not been respected. President Biden has said it himself. Given these things, you know, respecting humanitarian law is such a foundation of who we are, how we conduct conflict, how the U.S. uses its, you know, taxpayer funds to support this conflict, how the war is being conducted has an impact on how we see ourselves as moral people or as people that have values.

Every single soldier, every single member of an armed force that is participating in this has to go to sleep at night thinking about did they conduct themselves in a way that will essentially be honorable. And so I worry about the implications for U.S. policymakers. If the U.S. is essentially saying this is the way war should be fought, what does that mean? I hope there’s no future conflicts, but in a future conflict in which the U.S. could be engaged, what does that mean? And what does that mean for things like the reforms that the Defense Department has done in the U.S. on civilian harm mitigation and response, where there’s a whole section on allies and partners and on partnered operations?

So when I see the news about how the U.S. is specifically supporting the IDF, I do question what does this mean for this important reform which was years in the making, you know, or kind of coming years too late for what kind of people that we are, and how our taxpayer funds are used. So my concerns are both for the Palestinians, and what is left, but also for, you know, the militaries that are engaged here, and what they think of themselves, and how – you know, how they’re thinking about the erosion of IHL.

Dr. Morrison: Thank you. We’ve got just a few minutes left here. I’m going to ask Yasser to start off, and then Avril, and ask Scott to close. Just what are the – what are the key messages you would like to leave today for an audience – a predominantly Washington-focused audience, that’s very divided but very seized with this issue. This issue has gotten remarkable levels of attention, right and left. It’s a daily thing. It’s on every front page. It’s on every broadcast news. And the importance of having the three of you here today is you’re speaking from firsthand knowledge and experience, over many months of this tragedy. And oftentimes that voice is missing, frankly, in the debates about what is happening, and what – how do we need to focus our thinking. One month into this escalated phase of the war, nine months into – following October 7th – the tragic death of 1,200 at the hands of Hamas – and the war that began almost immediately after that inside Gaza.

Over to you, Yasser.

Dr. Abu-Jamei: Well, a ceasefire will be reached one day or the other. I hope that this is going to be very, very, very soon. That’s what I pray for. And with that, I’ll just bring your attention to what happened after 2014. The removal of the rubble took about nine months. Reconstruction – the beginning of reconstruction of the first building that was destroyed began one year after the ceasefire. It’s very important to begin clearing the rubble as soon as possible, at least to make children – I think, show them that things are going to improve. And to begin the reconstruction as soon as possible, because with every building that is reconstructed, or rebuilt, with every house, some hope comes to the community that we are going to build back, and that things are going to be better, and that our children can really enjoy some sort of peace.

And with peace, this is very important, you know, let’s try to ensure one way or the other that what happened will never happen again. And I think the international community and the lead international community players should rethink their strategies in dealing with what happens in Palestine, with the Palestinian-Israeli conflict, with the occupation. The international community have failed, not for years but for decades. And the proof is what we see at the moment. So please reconsider the way you are dealing and managing the Palestinian case. Please keep in mind that there are international laws that need to be respected. And please keep in mind that the suffering of people, that the lack of living, and dignity, and peace cannot be the foundation for any lasting peace. Thank you very much.

Dr. Morrison: Thank you very much. Avril, your thoughts.

Ms. Benoît: We’ve talked about international humanitarian law and how it’s being subverted here, with the support of the U.S. and other governments. But maybe, just as a concluding remark, I’ll also mention the International Court of Justice. In January, it recognized a risk of genocide in Gaza and ordered Israel to take provisional measures to prevent genocidal acts, notably to allow humanitarian aid in. We’ve been trying, trying, trying. The measures have not been implemented by Israel, and the situation in Gaza has passed the threshold of absolute horror. Even over the weekend we could see the extent of it.

So in the end, what we can say is that we right now do not have enough hospitals beds, or medical supplies, or medical staff who have survived and are able to continue working. The situation has continually deteriorated. And too many of our patients are children, who, if they survive, will face a lifetime of disability for their wounds, the mental health consequences, and all the losses that they have to live with, in addition to long-term follow-up medical treatment. So what has been created here over the last eight months or so is going to take generations to heal.

Dr. Morrison: Thank you, Avril.

Scott, you have the opportunity here to put all of this into one last context for us. What are your closing thoughts?

Mr. Anderson: Thank you, Steve, for allowing us all to speak today. I think that we all agree that the thing that’s most desperately needed is a ceasefire. The hostages need to be returned to their families. And Gaza needs to begin rebuilding. This will be the work of generations to rebuild Gaza. The World Bank had said it would take up to eight years just to remove the rubble, which is an incredibly long time. Which just speaks to the scale of destruction. And what people need is hope for the future. That starts with a ceasefire. It continues with rebuilding. And hopefully out of this horrible tragedy that has occurred for everyone, we can look at how we can build back better than we did before. I think there is an opportunity here to make Gaza better than it was, to look to the future, and to look to a better, peaceful future for everyone and their families. Thank you.

Dr. Morrison: Thank you, Scott.

We’re at the end of our hour. I want to offer a special thanks to my colleagues who’ve made this production possible – Sophia Hirshfield and Michaela Simoneau, who work with the CSIS Bipartisan Alliance; Eric Ruditskiy and Dwayne Gladden, of our remarkable production team here; and, obviously, my colleagues Michelle Strucke and Jon Alterman, who have joined with us in putting together this series, in which we will continue in the coming weeks.

Scott Anderson, Yasser Abu-Jamei, Avril Benoît, you’ve shown remarkable commitment and remarkable courage in your work and that of your organizations. And we’re very thankful to you, and inspired by you, and grateful that you would make the time to be with us today to share your thoughts. I know you’re all operating under very intense pressures and demands. But we’re in your debt for the work that you do. And thank you so much.