Humanitarians

The conflict in Gaza has now entered its fifth month, with casualties nearing 100,000, of which approximately 30% have resulted in fatalities. The ongoing hostilities have led to extensive damage across the Gaza Strip, damaging the majority of houses, impacting both governmental and non-governmental facilities, including numerous hospitals and health facilities. Additionally, critical infrastructure such as roads has been severely affected, disrupting communication networks, and hindering motorized travel within the strip.

A comprehensive review of the situation in Gaza reveals that all aspects of public life have been significantly “compromised, necessitating substantial investments and long-term efforts to address the extensive damage and losses incurred as a result of the ongoing conflict” (UNCTAD 2024).

One of the major victims of the war on Gaza is governance. There are two governing bodies: the local Gaza government and the UNRWA. Israel war on Gaza publicly aims at overthrowing “Hamas government”. However, the war involved besides Hamas officials killing and detaining other government employees, destroying buildings, municipalities, archives, logistics and warehouses, destroying de facto the possibility of day- to-day governance, crucially needed to distribute aid and manage crisis information.

UNRWA is principal supporter for the Palestinian refugees, accounting to 70% of Gaza’s population. Opposing UNRWA role is an old Israeli issue. Recently, Israel called for UNRWA closure/replacement beginning January , later accusing twelve of its employees of terroristic involvement. By end January 2024, fifteen Western

UNRWA donors suspended funding .

While the focus of both local and global attention remains on the casualties and injuries resulting from the conflict, there is a larger health crisis that is being overlooked, one that poses a far greater threat: the non-violent fatalities.

A study carried out over 10 years (2001 - 2011) demonstrated that among 4,596 battlefield fatalities, 87.3% of all injury-related deaths occurred in the Pre-Medical Treatment Facility (PMF) setting. This indicates that up to 12% of all war injuries resulted in mortality either during or after medical treatment (Eastridge,2014).
Other studies (Table 1, Geneva Declaration 2008) conducted in conflict-affected regions have demonstrated that non-violent deaths substantially surpass those direct violence-related deaths (See table 1 below). In ten countries affected by conflict, the ratio of "indirect" deaths to direct conflict-related deaths ranged from 2.3 times in the Darfur-Sudan conflict (2003-2005) to 15.7 times in the Sierra Leone conflict (1991-2002).

These non-violent mortalities come time after progressive deterioration of socio-economic and health determinants (WHO 2017) and increase with time. However, Gaza’s socioeconomic and health determinants were massively destroyed on the very onset of war in October 2023, and was complicated with tight land, air and sea blockade severely restricting the entry of essential supplies such as food, water, fuel and medicine, as well as impeding their distribution within the Gaza strip. Access through Rafah-crossing remains severely limited and symbolic air-dropping supplies remain irrelevant despite signals of hope it gives .

This article is an immediate warning message regarding the ongoing and forthcoming wave of non-violent deaths and an urgent appeal for immediate actions. The continuation (months-years) of the current situation directly threatens life of the majority of Gaza`s 2.2 million starving population (East 2024). Ending the war is the first life-saving measure. Even after the end of this war, the non-violent -indirect war death will continue, and it is reasonable to assume that this fatality will exceed by far the violent-trauma fatalities. The life of hundreds of thousands of Gazan´s is at stake

Priorities
It is crucial to emphasize that supporting socio-economic sectors that are critical to health, including temporary housing, water, sanitation, and hygiene (WASH) measures, food security, transportation, and communication is critical. The necessary consensus building, human- and material- resource mobilization and the necessary clearances of various parties is usually time-consuming and should be obtained in advance, not waiting for the “Day After” the war.

Within Gaza`s health sector:

Firstly, Gaza’s hospitals are largely out of function. Preparations for at least three self contained 400-bed field hospitals need to be made for deployment in Gaza City, Khan Yunis, and Rafah regions. This includes ensuring the availability of necessary power stations, staffing, and infrastructure.

Secondly, evacuation plans for patients, particularly trauma and ICU patients currently in Gaza’s hospitals, should be established. Detailed reports and classifications of injuries for all critical patients must be prepared, along with plans for transport and admission to hospitals outside the Occupied Palestinian Territory (OPT).

Thirdly, Gaza’s meagre resources were exhausted or destroyed. Major supplies exercise in the form of trauma kits, Necessary Emergency Health Kits, Nutrition Kits, Reproductive Health kits, etc., should be initiated for immediate deployment to all health facilities. Generators and fuel must also be readily available for shipment.
Fourthly, training of trainers on various should commence immediately, providing guidelines, equipment, and supplies for disease surveillance and response, as well as the evaluation and treatment of severe acute malnutrition (SAM). Preparations for Gaza-wide first aid programs in the field of Mental Health and Psychosocial Support (MHPS) should also be ready.

Table: Direct vs. indirect deaths in several recent armed conflicts (5)

Country Indirect deaths as percentage Ratio of indirect to
direct deaths Conflict mortality rate (per 100,000 p/y, average) Total conflict deaths(direct and indirect)
Kosovo, 1998–99 0 - 334 12000
Iraq, 2003–07 63 3.0 246 347000
Northern Uganda, 2005 85 5.6 476 26000
Democratic Republic of the Congo, 1998–2002 90 9.0 1316 3300000
Congo-Brazzaville, Pool
Region, 2003 83 4.8 n/a n/a
Burundi, 1993–2003 78 3.5 500 300000
Sierra Leone, 1991–2002 94 15.7 1101 462000
Darfur, Sudan, 2003–05 69 2.3 730 142000
South Sudan, 1999–2005 90 9.0 1178 427000
Angola, 1975–2002 89 8.1 676 1500000
Liberia, 1989–96 86 6.1 889 175000
East Timor, 1974–99 82 4.6 638 103000
Iraq, 1991 war 77 3.3 784 144500

References
1. UNCTAD. Gaza: Unprecedented destruction will take tens of billions of dollars and decades to reverse, <https://unctad.org/news/gaza-unprec...> (2024).

2. WHO. Determinants of health, <https://www.who.int/news-room/quest...> (2017).

3. EAST, A. A. M. UN warns about ’increased risk’ of malnutrition in Gaza, <https://www.anews.com.tr/middle-eas...> (2024).

4. Eastridge, B. J. et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 73, S431-437, (2012) DOI :10.1097/TA.0b013e3182755dcc

5. Geneva Declaration (2008). The Global Burden of Armed Violence, figure 2.3 P40 <https://www.unodc.org/documents/data-and-analysis/Crime-statistics/Global-Burden-of-Armed-Violence-full-report.pdf