Gaza: The Human Toll—Episode 7

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This transcript is from a CSIS event hosted on March 1, 2024. Watch the full video here.

J. Stephen Morrison: Hello and 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. This is the seventh episode of our broadcast series at CSIS, “Gaza: The Human Toll.”

We’re going to be joined today by Avril Benoît, executive director of MSF-US. Welcome, Avril.

We’ll be joined by Lana Wreikat, deputy director of UNICEF Emergency Operations. Lana, thank you for joining us.

And coming in from Jerusalem, Rik Peeperkorn, WHO representative for the occupied Palestinian territories. Rik, thank you so much for taking the time to be with us today. I know how pressed you are.

And my colleague Michelle Strucke, director of the CSIS Humanitarian Agenda and director of the CSIS Human Rights Project.

I want to offer a special thanks to my colleagues who’ve made this all possible, in particular Sophia Hirshfield, colleague in a in a Global Health Policy Center; and the producers here, Eric Ruditskiy and Qi Yu.

A few quick remarks before we move to hear from our guest speakers here today. Today is March 1st. We’re approaching the five-month mark on the war in Gaza. Yesterday, tragedy struck, and I’m sure we’ll hear about that, in Gaza City – over 100 dead, hundreds wounded; another instance – another dramatic instance of lawlessness, violence, mass death, breakdown, and horror amidst controversy over exactly what has happened. We are in the midst of unprecedented existential peril for UNRWA, the U.N. Relief and Works Agency for Palestinian Refugees, a central institution in the delivery of medical care, education, and support for the displaced. We are seeing dramatic holdups of mass food deliveries.

We’re seeing – we crossed the threshold this week in which one in 20 Gazans are either dead or wounded up to this point. We’re seeing a turn to air drops, another sign of desperation and breakdown. Medical care and health providers, as we’ll hear, over 100 detained, facilities and staff caught in the middle of the war, under siege in ways that we’ve seldom seen before this. The siege of Rafah looms as Ramadan approaches, on or about March 10th. A peace deal has proven elusive. And, in essence, the projections that many made early in this war that little stood in the way of a continued drift into unspeakable suffering is proving to be true. We’re not seeing a reversal of this dramatic push in this way.

So today, we’re going to hear again, as we have in earlier episodes, from experts who have a command of this subject that’s quite exceptional in terms of their respective organizations having direct on-the-ground operations and operational knowledge. These are institutions that operate under extreme circumstances and with exceptional commitment and courage in the face of the threats and the obstacles to performing their duties.

I’m going to turn to Rik Peeperkorn to kick things off with a few minutes, eight or 10 minutes, of remarks, just to summarize where WHO operations stand and the broader picture as you see it, Rik. You’ve been kind enough to join us several other earlier episodes. And we’re very grateful for that and grateful that you’re making time for us. Then we’re going – I’m going to turn to Avril Benoît and to Lana Wreikat for their remarks. And following those opening presentations, Michelle and I will have a chance to sort of carry the conversation forward, responding really to what the three of you layout. So over you, Rik. Thank you.

Richard Peeperkorn: Thank you very much, Steve, for having me again. And just to – yes, I’m now in Jerusalem. I just a week ago – bit more than a week ago I was, again, on a second mission to Gaza for more than two and a half weeks. And just to say – so I did the same in early – from early to the end of December. So I can compare as well a little bit. I think you mentioned this is your seventh – the seventh episode on this. And we probably all wish that your next episode will be about recovery and reconstruction. I want to maybe start with that.

I mean, we all know the figures. You see the headlines, that over 30,000 people killed in Gaza, mostly women and children, over 70,000 people injured. I think we also don’t discuss often – too often about that. All the injuries so I witnessed as well, as a medical doctor. And we visited many hospitals and we delivered a lot of supplies. I’ll come back to that later. Just horrific injuries and horrific trauma injuries, burns. I’ve never seen so many amputations in my life, including among children. And then there’s also an estimated 8,000 people still missing under the rubble.

And at the moment what you see these 2.2-2.3 million Palestinians in Gaza. It’s an – I don’t know how to just talk – words is very difficult to describe this humanitarian catastrophe and these inhumane conditions. We see serious risks of food insecurity, starvation, famine, and disease, which has never been an issue in Gaza. I just want to come back to that. Gaza used to have a pretty well-functioning health system. Yes, there were issues, et cetera, but good health workers and many – 25,000 health workers, 11,000 nurses and midwives, and 5(,000)-6,000 medical doctors, 600 specialists, et cetera. And what we see now also, the desperation, the scarcity led to a neared total breakdown of law and order.

And you mentioned the incident from – horrific incident from yesterday. But there’s many other incidents we see. And even when I came now back for the last couple of weeks compared to December, even way more internally displaced persons, specifically in the south, communicable diseases and unsanitary conditions, et cetera. And over 2 million people extreme – facing extreme food insecurity. And, of course, for women and children the greatest risk.

The health sector is collapsing. We have now only 12 of the 30 hospital partially functional – 12 out 30. So every time we talk about the figure, an enormous amount – 70 percent of civilian infrastructure; homes, hospitals, schools, water and sanitation facilities – destroyed/severely damaged. So this will take such a monumental effort if you talk about recovery and reconstruction.

Maybe later you want to go about – into the possible incursion into Rafah, which, of course, should not happen. It would be an utter humanitarian nightmare, above what’s happening now, especially when you see 1.4 million Palestinians cramped in a town that used to – in and around town which used to have 200,000 people.

I know Rafah well. It has always been a sleepy town, with too little of everything. And also in that area there’s only three hospitals, which are partly functional, supplemented by three field hospitals. We kind of lost Nasser Medical Complex. I want to get back to that, but that’s another hospital lost. So even if you think about that, you talk about a total of just 450 beds for 1.4 (million), 1.6 million people.

Now, I want to say something about the shrinking humanitarian space. We have had a lot of discussions on that over the past, difficulties actually to implement and undertake missions for, one, U.N. and their partners, and within Gaza and specifically to Khan Younis and the so-called middle area, but also to the north.

Yesterday – I want to say maybe something small positive – with some U.N. colleagues we had a good discussion with the civil administration, the Israeli side, and they encouraged and confirmed that they would be opening up missions to the north. Currently there’s a mission from WHO, that mission going to Shifa Hospital to urgently bring fuel and medical supplies.

So I’m really concerned about this mission, by the way, because specifically also the events from two days ago, how this will – how this will go and how this will happen, because people are not only desperate; they are also very angry, and understandably very angry, because food and water are, of course, the first needs, et cetera. And then when we bring in medical supplies and fuel, we’ve had in the past sometimes a little anger, very well and understandably.

Now, on Nasser, the medical complex, so when I was there two, now, weeks – I came back a week ago to Geneva and now again back to Jerusalem – we had difficulties accessing Nasser Medical Complex. And we addressed a number of requests to go there, which was not allowed. Then finally I went there with a senior WHO colleague – (inaudible) – and UNRWA to deliver fuel. We got stuck, I mean, like, the Khan Younis area. And it is all so close. When you come from the coastal area and go to the Khan Younis area, it’s all incredibly close. And within no time, you’re in a kind of semi-warzone – a lot of IDF, a lot of tanks, et cetera.

And we – the first time we couldn’t deliver the fuel. The fuel truck was stuck. The roads are all destroyed. Every other building is destroyed or partly destroyed, something like – it’s the same what I saw six weeks ago in Gaza City. I mean, like, that reminded me of these pictures of Grozny, et cetera, we have seen. And when we were allowed to get into the compounds, and we wanted to have a brief discussion with the director and to get into the hospital to make an assessment – to make an assessment and to plan for evacuation, because we heard – got all the stories from inside that the situation was hopeless, the hospital was actually not functional, and a lot of patients need to be urgently referred – we were not allowed that day. The next day we came back. We got a tanker out of the ditch, et cetera, with assistance, and fuel was delivered. The generator was still not working, so there was no electricity. Again, we were not allowed to enter the hospital. It’s a large complex, et cetera.

We could discuss with the director then, who was a(n) incredibly brave person and told us about the approximately 200 patients inside, of which he considered 40 to be evacuated immediately. But he actually said everyone needs to be evacuated, and also the staff. He didn’t even have a good overview of the number of staff because there was – he couldn’t move from one building to the other building. And so, again, we asked if he could make an assessment and go. We were not allowed, but he got all the information.

The next day I couldn’t join that mission. I had to go to another mission. My team was getting into Nasser Medical Complex, and they actually – they started the process which took days together with the Palestinian Red Crescent, and again OCHA and UNRWA, to get critical cases referred. And over a number of days, 72 critical cases were referred.

What they saw in the hospital, Nasser Medical Complex, was that, like, the Shifa of the south. And we have worked so long, for four decades, with Nasser Medical Complex. WHO supported the limb reconstruction center for many years, actually, to prevent amputations. And being there so often – and actually, MSF also supported that center. We couldn’t reach the medical – the central medical store, but from all the information we got that was the store is destroyed and the supplies are gone, which is also very painful not only for WHO, UNICEF in part, is because a lot of us provided medical supplies to that place; and also not only for Nasser Medical Complex, also for other hospitals south of Wadi Gaza.

Now, the cases are being referred. And then you had a sparkle of hope because director and staff, they were – I mean, they were so focused and they were still doing what they could do with no electricity, a lack of food and water, with a lot – a lack of the right supplies, which we – some of that we brought in. But they were all so desperate. They didn’t believe that they would make it, so they were initially saying, like, to me – and I know this director well – you know, this is fantastic that you are here, but, WHO and the U.N., you will not be able to help us. And I assured that we would get back to them. Really happy that we did, and we got cases referred, and we did that, and then helped to clean up that hospital a little bit. It’s a real mess and, well, nonfunctional.

Then what happened – what I understood from my team, so I’d left already Gaza – that beds had been taken as supplies by the population. And, yeah, it’s just a combination of desperation – the sheer desperation among the public.

I just want to make the point that we assess also now the vulnerability of vital services. And what we have witnessed, of course, over and over time again is the degradation, the dismantling, and the destruction. And it is not only about direct attacks, but when you get a war so close to a hospital nothing can come in and out. We cannot deliver the supplies, WHO, I mean, like, what is needed. Very quickly, a hospital which is partly functional become(s) barely functional and nonfunctional, and it cannot happen.

Then the team – WHO, again, and UNRWA – also went to Al-Amal and the PRCS hospital where we first, again, transferred patients as well. And we are very concerned about the – what you also already mentioned, Steve, in your introduction, the number of health worker detainees, including, you know, the PRCS workers coming from Al-Amal.

Maybe I want to close by saying – because I know the other ones want to ask, and I’m sure we’ll get back to some of the topics – but say something about the health systems and the functionality I discussed. And this is, of course, another area that we – besides the fear which I saw in people’s eyes in Rafah – like, what’s going to happen to them, including our own staff – everybody’s scared what’s going to happen if there would be really ground operations in that area, because it would mean movement of people – one-half million people – (inaudible) – but where to go. There’s no safe place, and everything is crowded. So going back north, which is not possible? To the Mawasi area, which is also cramped, et cetera? To Deir al-Balah, which is completely cramped? So, where to go?

It would, of course, only add to this enormous misery. And even hospitals – like, some of the field hospitals, the – from the International Medical Corps will have to be shifted, and will have to close, and which will have to move because they will be in the firing line, just like the other functional hospitals still in the Rafah. Al-Najjar Hospital, which is a very small hospital – it was supposed to be primary health-care center for 40 beds; now more than 350 patients – they also would be in the firing line. So you know what’s happening. You cannot compensate that with, oh, we have a few more field hospitals here left or right, et cetera. Absolutely impossible.

And then, of course, we see the diseases and the malnutrition. You’ve seen the reports about children dying at Shifa and Kamal Adwan in the north, due to starvation. And this actually shocking, because Gaza never had a malnutrition problem. Never ever. There was some micronutrient deficiency among pregnant women and a few migrant, that was it.

And if you see also the report, the assessment was done on nutrition vulnerability in Gaza, that in the north you suddenly see that 15.6 percent, or one out of six children under two years old, are acutely malnourished. And of these, 3 percent suffer from severe wasting. That is shocking. That’s talk about the north. And in the south, a little less; 5 percent of children under two acutely malnourished. And this is what we also discussed with partners and with the authorities, et cetera. It’s not just about bringing food, which is now the biggest priority, bringing food also to the north; but it’s a combination. You have to combine it, of course, food. Then you have to think about wash, water and sanitation. And of course, health, because it all links – linked to – linked together.

Let me leave it here. And I’m sure there will be some other questions from your side. Over to you.

Oh, maybe one thing which was also shocking for me. Like, in Nasser, so when I was there last time, we also transferred patients from Al-Ahli Hospital in the north to hospitals in the south – to Al-Aqsa, but also to, for example, Nasser – and, one, number of the patients we transferred then, so we met them again in this besieged Nasser Medical Complex, this mess there. So can you imagine, patients being transferred from one place under horrifying conditions to another one, and the same happens there?

And this is may be my last plea I want to make. I raised it last time. We estimate, the WHO, that 8,000 people – 8,000 children, women, men, patients – need to be medical evacuated into Egypt, and then from Egypt to probably other places. Many countries have offered their services for that. We estimate 6,000 related to this war – trauma, multiple trauma, burns, et cetera, spinal fractures, amputations, et cetera. But 2,000 what you call the trauma diseases. And, again, before this crisis an average of 50 to a hundred patients per day, also with our support, however go through Erez to East Jerusalem or West Bank. So you talk about 50 and a hundred per day, so 250 to 500 a week, must – 2,000 a month, and 50 – 40 to 50 percent were cancer related, et cetera. A lot of them need to be referred out of Gaza as well.

So that’s a huge plea. We have brought up and we’ve come up with a proposal. We need to get a workable mechanism to get a formal medevac out of Gaza.

Over to you.

Dr. Morrison: Thank you so much, Rik. That’s very powerful. And I very much appreciate the detail of – the personal detail you’ve given us of the missions that you’ve performed in recent weeks, and what that – what that revealed to you. So thank you so much for taking the time to walk us through that.

Avril Benoît, MSF, thank you so much for coming over today to be with us.

Avril Benoît: Yeah. Thanks for having me. And I really appreciate also what Rik has outlined there, and maybe we can add a few things from our perspective as Médecins Sans Frontières, or MSF, also known as Doctors Without Borders.

We are seeing, with all the latest news, that there continues to be – in the ways that this campaign is being waged by Israel, that there are choices being made. And we – (laughs) – we really have done everything we could to bear witness to what we see on the ground, of the collective punishment, the mass displacement, forced displacement of people, cutting people off from food, from water, from medicine. And even what Rick was just mentioning there, about, you know, what happened with that recent convoy. We don’t have all the details now but one of the things that struck me immediately was how Israeli authorities labeled the people who had seemingly surrounded the trucks that were bringing in supplies as the mob – you know, this dehumanizing language. Why they conducted a distribution or a convoy in that particular manner in that place with – you know, with tanks all around, we have a lot of questions about the wisdom of that approach. But the very fact that we’re blaming the victims here all the time from the beginning – blaming the victims for what, for living in Gaza and being desperate for food?

In our medical facilities that we support – and it was mentioned Nasser Medical Complex was one of them – we have colleagues supporting, say, four hospitals in the south, a couple in Khan Younis. We also have colleagues who are volunteering, if you will, in Al-Shifa, doing what they can wherever they happen to be stuck. And the description there of how even the hospital director cannot move from one part of the hospital to another for fear of being shot is something that, in addition to the fact that you’re cut off from communicating with your colleagues, means that we don’t even know how all of our staff are doing. The ones that were in a shelter in Khan Younis last week or a week before – you know, just middle of last week, 61 people, so staff of MSF plus their families, in a location that was supposedly deconflicted as far as that works or doesn’t really apply in Gaza because nowhere is safe. Here they were civilians in a clearly labeled, identified, logofied facility as a shelter, which is something that aid organization are having to do just to provide some safe place for our colleagues and their families, large families. It was hit and a shell killed people. We had six deaths. Five out of the six were women and children. And you have to wonder, you know, why are these choices being made? What is driving all the attacks on hospitals? What is – what is really behind this campaign to starve people?

Now, we’re hearing a lot about famine and the looming threat of famine, and we would wish for some sort of ceasefire to be able to do a proper assessment, to really check on people and see how they’re doing not only in the south but in the north, in the places where we just don’t have the data ourselves. We have no way of going around now to see: Is it – is it different among those who cannot reach a medical facility as opposed to those who are in a medical facility? What are the ages? What is the acuteness? But for sure we know that these micronutrient deficits/malnutrition will cause a lot of vulnerabilities. Pregnant women, not only for the gestational process but also if they’re lactating, you know – post-natal care, when you have somebody who is – who is so lacking in nutrition, how are they supposed to keep their newborn alive through breastfeeding? You know, it all brings together a picture of real desperation. And so when these things happen – when people are scrounging around, taking a lot of risks to find anything to eat, even to the point of maybe trying to surround a convoy just to see what they can get out of it – you can understand, you know, why people would be compelled to – out of an act of desperation to support their families, do what they have to do to survive.

And it’s – it also calls to mind, you know, this – when you bring in medical supplies how people have maybe a reaction of disappointment if the convoy is filled with medical supplies or fuel to run the generators that run the hospitals and all the lifesaving machinery in there. That is very common. It’s universal. We see it in many humanitarian crisis zones, is that you’re be working in a facility, coming and going, and what people approach you to ask about is, do you have any food. It is something that we see all the time. It becomes a major preoccupation. And it’s – it may be for us, you know, not something that we’ve got in our pocket or in our truck; we’ve got medicines and we’ve got fuel. But for sure in Gaza it is becoming a major preoccupation for everyone. The water situation, of course, is also making people sick.

In the patients that we’re seeing, we discharge patients too quickly, even when they’ve had major surgery, so imagine somebody coming in for a Cesarean section; you have to make room for the next trauma patient to come in and so you discharge her as quickly as possible just to make space in an operating theater that might already have a few operations going on at once. I mean, the conditions are just awful. And so four hours later that mom and the infant, the newborn, are sent where? To the tent encampment or into some sort of shelter that is partly bombed out with dozens and dozens of other family members living in deplorable conditions with one toilet for every 700 people. I mean, the whole picture is just devastating in terms of what you’re sending people into. And we’re seeing – as a consequence of people being discharged so quickly, of the lack of medical supplies to the point that surgeons are reusing gauze, you know, gauze that’s filled with blood; they rinse it out, they try to sterilize it, and then they have to reuse it. What else are they going to do? And we discharge people who then are exposed to infections. People are coming into medical facilities with extreme infections, to the point that they require amputation. They could have been treated, you know. Under the normal circumstances of a well-functioning health system, it would have of course been a major strain, but under these circumstances, with a health system that’s pretty much collapsed, we need to acknowledge that it’s just impossible.

The medevac situation includes not only those who have the trauma cases, but as Rik mentioned, it’s people who are undergoing treatment, so cancer care, people with severe epilepsy, you know, children who require that ongoing care. And how will we know what people died of? The direct and indirect consequences of the war are killing people. We know that. It’s plain to any observer watching. But only when the dust settles a little bit and we can actually talk to people about, OK, your mother died, what were the symptoms? What were the circumstances, these retrospective mortality surveys where you try to figure out, you know, what was it? OK, she had diarrhea first and then she had seizures and then – and she died. A lot of people, of course, are not dying in hospitals. The ones in hospitals, you know, there might be some sort of marker; well, died of bleeding, died of trauma. But for all the ones in the community, we have no idea.

There’s a lot of concern, of course, also about this question of a full-scale ground invasion in Rafah. I mean, this is an urgent, burning issue for us, because as Rik was describing, you’ve got 1.5 million people, many of them were told, go to Rafah, that will be the safest place for you, so they steamed in, living now in deplorable conditions. And just this very thought of a ground invasion, we have so many questions, like what’s the plan here? What’s the plan for the civilians? If you claim to care about civilian life and mitigating the harm coming to civilians in your conduct of this campaign, what are you going to do about the fact that the roads are covered in rubble and you can’t just move people along those roads from Rafah to other locations next door or up the strip? What are you going to do about all these people that require sustaining care that are in-patients in hospitals who need medical transportation? They need full-kit ambulances. How are you going to have enough of them and which hospitals are you going to take them to? What’s happened to – what have you done to those hospitals that you now – I mean, you have to figure out where these people are supposed to go.

One of the things that of course is very important to the people of Gaza is that if there is an evacuation of medical staff or wounded people or whatever it is, civilians, a large scale, there’s this sense of the right of return – you know, what are you going to do to guarantee – if you try to get people through Rafah into the Egypt side of things, what is their right of return and what are they supposed to return to if you’re destroying all their houses? Seventy percent, 80 percent of the housing stock is now flattened. We don’t know about the unexploded ordnances that might be littering all these battleground areas.

All in all, you know, the questions about the future are looming. And with this threat of a full-scale ground invasion in Rafah, we just can’t imagine that it will be anything but a massacre. We just don’t – we don’t see a plan for how to protect the civilians. And that is an imperative for the Israeli forces that will be carrying this out.

So just to say, finally, a word about the aid workers on the ground. We have more than 300 – roughly 300 are Palestinian who are there with their families. We’ve lost touch, as I mentioned, with some of them because of the cutting of phone lines. It’s not always possible to check in on people. That becomes a major effort in itself just to ask people to please check in and let us know you’re OK. The detention of workers – we have one; we don’t know exactly what has happened since he was detained. And we can only call for his safe treatment and to be treated humanely, with dignity, which has not always been the case with hospital workers detained and, you know, paraded unclothed on the streets. So we worry about our staff all the time.

The international cohort is small and it’s very limited in terms of what they can actually do. Everything we do, all our movements have to be notified to the Israeli forces, COGAT. We don’t mind doing that. But then to have them attacked – we’ve had, as I mentioned, shelter attacked, hospitals where we’re working attacked, physicians killed while at the bedside of their patients in hospitals. We’ve had vehicles bulldozed, clinics on fire.

You know, all of this for us is so objectionable. But we can’t slam our fist on the table loud enough at the U.N. Security Council, which we did last week; you know, just this notion that health care is so under attack and the humanitarian sector at large is under attack. It’s not just the medical. We’re focused on that here. But, I mean, this is a violation of all the norms of law. I mean, you just name it and you’ve got a problem.

So in terms of the future, of course, what we would love is for the ceasefire to happen, to stop the killing and bring in more humanitarian aid that is commensurate with the needs. Right now what we’re able to bring is far too small. It is a drop in the ocean. And it’s for us an untenable situation to be in, because we have staff on the ground that we’d like to be able to empower to do more, to bring in everything that’s needed here to alleviate the suffering, to save those lives through the medical programs that we might be able to offer. And right now, frankly, it's impossible. We’re doing the best we can, but the conditions are really – especially with the looming invasion in Rafah, we just can’t see a way through.

Dr. Morrison: Thank you, Avril. That’s very powerful. I appreciate very much that you’ve come and shared with us that. We read the testimony from last week, that and other testimony; very traumatic at the Security Council. And it’s very valuable to have you here, to say those words here.

Lana Wreikat, thank you for joining us. It’s great to see you again; UNICEF.

Lana Wreikat: Thanks a lot, Stephen.

Very difficult to follow after Rik and Avril. I think they give a very detailed overview of the situation and the bottlenecks and constraint we face as a humanitarian community. Our staff are the same. We have 200 people working on Gaza, 47 inside Gaza, 100 in Jerusalem, and the rest from the neighboring countries, just trying to support and push supplies through and try to negotiate, trying to also support our national colleagues inside. It has been definitely a horrific situation.

From our end, unfortunately, we’re seeing and witnessing that worst-case scenario unfolding in Gaza as we speak now. We’re now into the fifth month of this crisis. And it’s children who are paying for this war with their lives and also with their futures. They’re losing their future. And with the whole destruction and damage of infrastructure, social services that children and their families rely on, this is basically going to have long-term implications, not only for them, if they make it alive. It’s going to be basically having a long-term implication for the region and beyond. So it’s really a call for a ceasefire. That’s the only way we can basically bring about change. As Avril mentioned, what we’re bringing in is a drop in the ocean. You need to have full-scale services back into – back working. You would need also to have the commercial sector.

I mean, what happened yesterday was very unfortunate, but it’s because people are desperate. I talked to one of our colleagues in Rafah, and she was basically telling me stories about children that are dying slowly. Her relatives, people are eating weeds. They are using also weed and they are using also animal feed to make bread. I’ve heard also very difficult accounts of colleague – one of our colleagues lost his father. His father was in the north, and he was not able to go and bury him. So we’re hearing these stories every day.

If we want to go back to the whole issue of nutrition and malnutrition, from our end since December we’ve really warned against a nutritional crisis and famine. We don’t have the numbers, the accurate numbers, as Avril ever mentioned, because of insecurity. We’re not able to do very detailed assessments. However, I think Rik mentioned specifically in the north one from six children under two in the north are facing acute malnutrition, and the whole population as well is facing this acute food insecurity.

And this is, of course, related to malnutrition and the famine. What we’re going to see unfolding is also very much linked to the health situation. Ninety percent of children, if not more, are also having infectious diseases. From the UNICEF side, we do lead the nutrition cluster, but also our partners are exhausted. They also lack the minimum when it comes for them and for their families. They’re also worried about their security, they’re constrained in their movements.

And, again, from our side, while on the nutrition side, for example, we’re trying to provide curative and preventive support, getting in supplies, what we’ve been trying to support is to focus on the 300,000 children under two as well as 155 breastfeeding women. That basically was not possible to sustain for long because of also the pipeline that is also not sustainable to date. I think there has been many calls to try and facilitate the movement through also having other crossings in the north. It’s no longer possible just to operate through one crossing. The inspection, the bureaucracy, and also what we’re facing in terms of impediment is just basically on the on the rise.

In terms of Rafah, I think what we’re seeing now is also 600,000 children are also trapped in Rafah. And their also future – we don’t know if the situation is going to be resolved. We’re working around two different scenarios, an increase of hostility but also a pause. And both scenarios, they require also massive preparation and a number also of steps so that we are able to operate and provide the support that is required at scale.

I mean, in addition to the lifesaving – and we talked about the health, about the water – but also we have 17,000 children who are also separated from their families and unaccompanied. And this is an underestimation. And, again, I mean, we really don’t know the numbers. The mental health situation, psychosocial support, these are things that the population of Gaza will live with for ages and for years to come. So how are we going to work also around these issues also as a humanitarian community?

Unfortunately, as Rik said, we have hoped when we reach this seventh episode that we will talk about recovery, rehabilitation. But it’s really difficult. I think, peace now is what we really need. And it’s becoming more complicated, not only in Gaza but the whole of the region. And we know that this will have far consequences across the region.

Dr. Morrison: Thank you. Thank you. The nutritional studies that were just recently released – that I know you were involved with, and WHO was involved with, and the IPC the group that did the determination – those, I think, were profoundly alarming. And they received enormous attention.

I want to ask my colleague, Michelle Strucke, to join us now and share her thoughts into what we’ve just heard from Rik, Avril, and Lana. Over to you, Michelle.

Michelle Strucke: Thank you so much. And thank you to all three of you for the heroic work you’re doing under these deplorable conditions. It’s really sobering to hear just how much worse things are getting as we track this crisis. I wanted to share just a couple themes that I heard from each of you to emphasize points for the viewers. One is just that, of course, the aid that’s getting in is not enough. The headline recently was that aid deliveries had dropped by 50 percent. I want to remind everyone watching that there’s still no electricity. Gaza is still, of course, experiencing the severe shortages that we heard about in food, water, sanitation – all the really basic necessities that people need to live safely. And these disruptions impacting the populations, of course, are leading to that civil unrest.

So I wanted to say a word about that. The desperation of the population we’re seeing now is preventable desperation. They did not have to get to this state. It’s not normal in a humanitarian crisis. We do see crowding in humanitarian crises around the world, we see people getting to difficult states. But to see what we’re seeing now in Gaza of the population is a result of the situation that they’re in. And I wanted to say that especially because, given the lack of sympathy for Palestinians that we’ve seen in particular coming out of kind of the sentiment that some of my security colleagues that track the kind of military situation have shared, who are looking at the politics of Israel.

The lack of sympathy – I think it’s important to say that the Palestinian population, they’re not – this is not an inherent characteristic of that population, that they are acting in in desperate ways to try to get food when aid is coming in. It’s a result of this situation. And I’m saying that because that sort of bias that exists, and blurring of sort of the lines that we’ve talked about in this broadcast before, that looks at Palestinians as somehow inherently violent, or dehumanizes them, I think that contributes to the choices that are being made about what aid they get and whether they deserve to get aid. So it’s an important point to be emphasized.

One other point is that, as we look at a potential ceasefire – potential cessation of hostilities happening, that’s being negotiated right now, even if that ceasefire did happen next week – which I think we all hope for desperately – the suffering would not stop instantly. An UNCTAD report recently that came out said that it would be at least 10 years for recovery of the devastation that has happened of the Palestinian economy and the civilian infrastructure. And, of course, issues, as colleagues here today mentioned, like malnutrition. Rik talked about how it doesn’t just – it won’t just go away if you give food. You have to also deliver health, water, and sanitation, and other related issues. And as Avril noted, malnutrition has ripple effects and consequences on the population. So those are important themes.

If a ceasefire is not reached, of course, the thing everyone is worried about is this potential Rafah ground incursion, which would be a catastrophe. And a catastrophe that, as Steve noted in the beginning, would be occurring during Ramadan, which is – while not all Palestinians are Muslim, for sure, those who are this is a holy month, a sacred time, a time of great celebration. And it – to have this incursion happen at that time would be more than catastrophic, when people are already starving. To think about not just that, but the ripple effect on neighboring countries that are watching, again, this unfold with the population.

One other point to raise is just that with policy options, I think, as authorities are considering what to do it’s worth highlighting that there are – this is not a hopeless situation where nothing can be done there. As Avril said, there are choices being made. And for policy choices, additional crossings could be opened, additional ports could be opened in the north to get aid in. The U.S. government is reportedly discussing military air drops into Gaza. And while nobody wants to receive food from an airdrop, or supplies, given the impassable roads, the horrific conditions I think it makes sense for everyone to consider as many options as they can. But it doesn’t take the place of sustainable solutions, such as a ceasefire. or additional aid crossings being opened, or the ability to get proper medevac out of Gaza, as Rik said.

One last thing to note before I close is just emphasizing the fact that nowhere is safe continually is such a horrific situation for the population and humanitarians to be in. The fact that the U.N. flag, the U.N. logo, the humanitarian logos are not being respected is really a severe degradation of international humanitarian law. The U.S., in its national-security memorandum that they just released, put a section in it that said that its partners that it’s delivering weapons to have to follow international humanitarian law. And it also said that they have to make sure that humanitarian assistance from the U.S. is delivered.

I think these are really important pieces of context to add to the policy discussion about what can happen and demonstrates that the U.S. government is, you know, from congressional pressure and popular pressure, is thinking differently about how to handle this. But it’s not soon enough, because, as Lana said, the people who are paying for this crisis are children, and it is their futures. This is a catastrophic but preventable situation, and I think more can be done.

Dr. Morrison: Thank you, Michelle.

I’m going to come back to our speakers. One issue that we haven’t focused on is what is the fate of UNRWA in this situation. What is going to – what are the options for making sure that it is not really eviscerated terminally in this period? And I wanted to get your opinion on that.

And in terms of high-level interest, what impact and difference does that make? We’ve had the Security Council meetings. We’ve had statements following the events, the tragedies and tragic loss of life and injuries in Gaza City on Thursday. We had statements made by Macron and others. This is – this crisis is drawing high-level comment from state leaders, multiple state leaders.

Maybe some comment from you on those two issues, among the other issues that Michelle just raised. I’m going to – let’s just – Rik, I’m going to come back to you for any remarks to what we heard from Avril, Lana, Michelle, and the issues I just raised, whichever you feel you wish to seize upon.

Dr. Peeperkorn: I think you raised – and thanks also for my colleagues, I mean, for all the comments and additions, et cetera. It makes much stronger. Thanks, Steve, as well.

So you raised UNRWA. I will say something about that, but I want to also come back to a few other things. And maybe one small thing is the airdrops, something that was mentioned as well.

You know, so I’m absolutely not against airdrop. Let me be very clear. And they can be – work in areas where they can be lifesaving intervention, and – but also in the volume of supplies that can be delivered in airdrop is much lower, and it’s often not always so well-prioritized that what we can deliver by trucks and over land. And it’s very expensive. They require extensive preparation, and specifically in a densely packed place as Gaza – clear not only the airspace, logistical transport, et cetera.

And the issue is that Gaza, it should not be needed; that the simplest and safest and most effective way to deliver aid to the people of Gaza is if it’s Rafah, if Kerem Shalom, there should be more entries. So, first – I think one of my colleagues rightly said, first, they’re still not getting enough aid into Gaza. That should be very clear. It’s simply not enough for the basics. Then the distribution within Gaza. And I think we – you have discussed this in many of your sessions as the reason why the distribution within Gaza.

Now we get some – finally, I mean, we’ve struggled. There’s hardly any aid that has gone to the north, for example, for thousands of people. But even in areas – Khan Younis, et cetera – now we get some encouragement that to the north is a little improved. Well – first see, then believe. We have this mission today at WHO to Shifa to the north, et cetera; still have to hear back from them, et cetera. But it’s – that’s just one small mission; a few vaccines together with – (inaudible) – medical supplies, et cetera. You talk about multiple missions daily, and the U.N. is ready to do that. Some of the roads, which have been incredibly damaged by all the tanks and fighting, et cetera, they can be easily repaired, partly repaired. I’ve seen it in other places, too.

Now, then, the entry to Gaza. There should be more entry points into Gaza besides Kerem Shalom and Rafah, and they all should really work. There should be more. Should be an entry point north – in the north of Gaza. That should be the pressure. And then you will note these airdrops, et cetera. You can focus on much more cost-effective med supplies. I want to make that point.

On UNRWA, I find it all essential here. I mean, like, when everything was happening, I mean, I can tell you that – and having over the last three years being here and then visiting Gaza every month for a week, and now more often and longer, the U.N. and partners’ humanitarian response to Gaza depends – actually, to OPT – depends very much on UNRWA. And also being – UNRWA being adequately funded and operational. And currently, no other entity has that capacity and delivery to go at scale and to assist the assistance of these 2.2 million or 2.3 million – 2.2 million people, who urgently need it in Gaza.

So I think it’s not only – the secretary-general has raised that, my own boss, the director general of WHO, Dr. Tedros, raised that, et cetera. An appeal to those who have now suspended their contributions to make sure that UNRWA can continue its operations, because it will be compromised already in March, by the end of March. And this will only deepen the humanitarian needs. And it will have a potentially cascading effect across the region. So that’s what I want to say about UNRWA.

And I just want to go back to malnutrition. I think it was – some of the things that have been said about that. And again, I want to make a point that before this crisis, we talked in Gaza, it was extremely rare. You talked about 0.7 percent of the children under five which we would consider acutely malnourished. Now, in this – in this small but focused survey now in the north and the south, we see 15.6 percent of wasting among children under two in northern Gaza. And that suggests a not only serious but incredibly rapid decline, and a decline in a population – in such a small population and such a small space in three months is actually really unprecedented, and completely unnecessary. Completely unnecessary.

Other little bit of what we get from that are that 90 percent of children under the age of two and 95 percent of pregnant and breastfeeding women face this severe food poverty, and that they consume two or less food groups of the previous day. And their foods – and they don’t – they get access to the lowest nutritional value. We talk about wheat all the time. And I want to get back on that one as well. So Gaza, yes, there was always a lot – the import for wheat was clear, and other items as well. But poultry, eggs, fish, but also fruits, vegetables, et cetera, were all produced within Gaza. They were actually self-sustaining on that area. Gaza produced a lot of fruits – fantastic, fantastic, sweet and nice strawberries, for example. Most of them is also destroyed. I mean, millions and millions of chicken are not there anymore; so no eggs, et cetera. That food also – there needs to be supported again. And why can people not go out fishing, et cetera, et cetera? And when you see the thing that 95 percent of the households are limiting meals and portion size to one meal a day, et cetera. So you can understand the – also the desperation and even more in the north and everything what is happening.

And you talked about the incident. I want to make it also very clear that – so the U.N. was not involved in those deliveries at all. So the question should not be raised to the U.N. in what happens in that horrific incident.

Maybe my last point is on the – what you said about high-level statements. And I think a lot of – I mean, specifically for the Gazans, I mean like that – and hope also in future shows – we talk about recovery and reconstruction, and you get some of the Gazans in your – in your show, Steve, because there’s so many experts and so much expertise there. At the moment, a lot of them don’t believe in this, high-level statements and high-level meetings. And people are incredibly cynical – cynical, angry, disappointed in humanity. And I completely agree with that. I mean, like, what we’ve witnessed over the month – and from all sides – I just want to mention it’s from all sides – there is, unfortunately, a great loss in humanity, and what is right and what is wrong, and why is this continuing in the way it’s continuing.

So, yeah, I think there’s a lot of cynicism and double standards and everything around that, and that’s not good. It’s not good for the world. It affects also a right-based approach. It affects also other crisis in the future. It affects our whole sense, how we believe in that we have to do things together, the multilateral approach and systems, et cetera. Indeed, it incites a lack of respect into all of that. And that’s not good for – definitely not good now, I mean, like, for the Gazans.

And I also want to make a point, I mean, like, there’s also – we are also deeply concerned. I can’t stand the word deeply concerned myself anymore, by the way, but if I say we are also deeply concerned about the West Bank and everything what’s happening there.

So I really – the only thing – and we didn’t even ask – I know that even one of your topics, one of the – your sessions went also to mental health and psychosocial support, and I’m glad that you raised that because many talk about health. We currently – we always talk about everything related to the war, and you talk about trauma and everything related to that, and supplies and equipment needed for that. But we – if you – finally, we are focusing now with other U.N. partners as WHO, but with the NGOs, I mean, like, and there’s many NGOs trying to do fantastic work, but also they would all like to expand. If you would ask my MSF colleague, if you ask the Save the Children or IC, et cetera, there are so many who would like to expand. We are coordinating these EMTs. But it’s – just simply the humanitarian space to do that is also not there.

And a lot of their staff, and rightly so, they’re also scared. They’re also afraid to – they’ve never – some of us – and myself, I’ve been seven-and-a-half years across the WHO realm in Afghanistan, so I’ve seen some horrific things there in Kandahar and Helmand, and in Uruzgan and Kabul. Of course, that’s a – I was part of – I worked in southern Africa during the whole HIV/AIDS epidemic when there were no ARVs, et cetera. So I’ve seen some grim scenes. And I’ve seen Rwandan refugees moving down on Lake Tanganyika. I’ve seen some grim scenes. But I rarely have witnessed what I’ve witnessed in Gaza over the last couple of months, and, seriously, it has to stop. We – (inaudible) – so often statements, et cetera. And I really hope that the next time we focus and we talk about reconstruction and recovery in whatever way possible, and you get some of the Gazan experts on your – on your sessions as well.

Over to you.

Dr. Morrison: Thank you, Rik. And we are taking that advice on board and we’re fully open to that – to that suggestion, and I very much appreciate you drawing our attention, which is an important message for us here in Washington, around the formidable cynicism that’s accumulated in this period and distrust of policymakers in the West including in Washington, D.C.

I want to ask our speakers if we could run a little bit over time. We’ve hit the one-hour mark. If we could take just a few more minutes to hear from Avril, Lana, Michelle, and then we’ll come back to you, Rik, for some closing thoughts.


Ms. Benoît: Well, I mean, just as far as UNRWA goes it’s part of a larger pattern of disparaging the work of humanitarian organizations that are trying to respond in Gaza and we see this all around, that there’s a disparaging of even the call for a cease fire as if that is somehow we’re apologists or providing cover for Hamas or somehow not speaking from a framework of ethics and concern for life.

So, you know, there’s a – there’s a whole machine that is looking to pick apart and cut down independent humanitarian action – principled humanitarian action that is trying to reach the most vulnerable. And in the case of UNRWA, you know, guilty until proven innocent. I mean, everybody jumped to these conclusions in deciding to cut the funding to them, and that is appalling. And so, you know, we should always be prepared to object to anything like that.

In terms of the long-term prognosis, of course, yes, we all want to scale up. Under the current circumstances, though, we can’t. And if there are, you know, so many calls for airdrops, that in itself is an indication of what a failure it’s been for the Israeli forces that are managing this conflict, the approach that they’re taking that it should come to that. I mean, yes, in principle, sometimes that’s necessary, but in this case there were so many other options and there continue to be so many other options. Let’s take the good ones so that even what falls from the sky or is brought in on trucks is actually distributed in a thoughtful way, in a secure way to reach those who need it most, as opposed to this chaos that is always going to be a factor when you do an airdrop over an urban area like this. So, you know, let’s just get realistic about where the responsibility lies, for the very fact that the U.S. government and others are trying to expand the conversation around airdrops, as if that’s a solution. It is absolutely not the solution. It’s an indication of failure. And then we see how it actually happens and all the goods fall into the water and people swim out to try to retrieve this waterlogged material. So all in all, that’s not the way to go.

So for me the most important thing is to stop all the fighting, the war – obvious statement – but also to recognize the political complicity of the United States in all of this, in choosing to use its veto power at the U.N. Security Council, in saying it’s concerned about civilian life and yet not acting in accordance with that. We know that there are many good people trying to work in the U.S. government, work in diplomacy behind the scenes who know the right thing to do, but in the actions of the United States, we don’t see much impact of all those words. And that, to me, is just a recognition for this audience and for you and your work in Washington, D.C., to relay this point. It’s urgent. And years down the line, the stain of political complicity is going to hang over the United States for generations, just as the mental health consequences are going to hang over these children as they grow up.

Dr. Morrison: Thank you.


Ms. Wreikat: I mean, on UNRWA in particular, from the UNICEF side we’re basically neither considering suspending collaboration or taking over any of their functions. We simply can’t. There’s no substitute for UNRWA. If we just look at the scale, I mean, they have 13,000 staff inside Gaza, and that’s massive. Basically, these are the networks we depended on to basically distribute supplies and help support also with multi-sectoral response in the shelters. More than 1.5 million people live in shelters that are run by UNRWA, so the scale of their operation and support – the fact that they also know the area, their key local responder that basically is working with the whole U.N., so our whole collective response will be compromised if UNRWA is not basically fully supported and functional.

I would like also to go back to the whole issue of erosion of trust. I mean, this is a problem and it’s not only in Gaza; I mean, we’re seeing it in many places. And it’s not very much linked to the misinformation or media; it’s also to how we’re basically operating, how we’re advocating, the advocacy, how, as a system, we came together in Gaza. I think the U.N. agencies, with our partners, we did our best, at all levels, to have one voice. Unfortunately, till now, I mean, we don’t see any positive change, but still I think we need to do more; we need to de-link the political agenda. It’s really very important. Otherwise, our access, our security will continue to be compromised, not only in Gaza but elsewhere. This is going to have really far-reaching consequences beyond Gaza for the U.N. and for the humanitarian community, so it’s really very important to think through this, as we basically still press for cease-fire. We will not able to deliver even if we have more crossing points, if there is no cease-fire. So that’s, for us, I think the key ask.

Dr. Morrison: Thank you so much.

Michelle, your last thoughts for today?

Ms. Strucke: Just one thing to emphasize here is just that I think that one of the big catastrophes I see in this from a humanitarian perspective is just that allowing humanitarian aid in, allowing people to have – civilians to have the basic things they need just to survive. Not to have an amazing time and have a great time in the war. Just to survive. Just to be able to feed their children, have them not die of malnutrition or preventable causes, or infectious diseases, or diarrhea, humanitarian assistance is a bare minimum.

And the fact that we see it so disrespected, so denied, blocked, logistically impassable, it’s a real preventable tragedy. So I think just returning to this idea of respect for the impartiality of these brave, independent humanitarians that are working every day at great risk to themselves and their families to get this bare minimum aid in, just for survival, I think going back to that respect can’t be emphasized enough.

Dr. Morrison: Thank you.

Rik, your last thought for today.

Dr. Peeperkorn: Well, I think the last point Michelle raised, I completely agree. So, finally, I mean, we all work for this – for the Gazans. But I think it’s – that has to be facilitated, and it has to be respected, and including the impartiality of all of that. So I think it’s – I think I really completely concur with the point, and actually all the points raised.

I make, from the health perspective, I mean, like, to just summarize the three key points. And I think the decreasing health functionality which we’ve seen over the last five months, of course, is incredible – dismantling, the destruction of health service, vital service, et cetera – and also completely unnecessary, is of course, that should stop. I mean, like, we cannot lose any other health services. In contrary, we have to expand and to build out, et cetera. And then there’s a lot of partners who are ready to do that, but they have to be able to, right? It has to be safe. It has – they need to have access. They need their supplies, et cetera. And this has all been – that has all been compromised all the time. And we have seen a lot of promises, et cetera. Well, first see, then believe. But this – so much more can be done.

The second one, I mean, I raised, again, this whole lack of medevac. I absolutely do not understand why this would be properly a major – it would also be a huge relief for completely over-exhausted health services and health workers if you can get 8,000 patients who need better care, who deserve better care, out of Gaza. Issues like detention and detention of health workers, really, I mean, like, we need to have much more – and also intimidation and abuse. We need to have much more attention for that. That should stop.

And then the access which have been both to Gaza, within Gaza itself, and discussed, et cetera. I have small hope that hopefully it will open up now more to the north. That’s only – that would be a small thing. But first – again, first see, then believe. The north needs to be flooded by food first, and then – indeed, like, you cannot just do just foods. It has to be a combination. We talked about wash, we talked about medical supplies, we talked about shelter, et cetera. It has to be a combination. And to clear up these roads, to make sure that they work, that is not that complex. That should just happen. It’s not that complex. And even if there’s no ceasefire, which we all – which we all actually plea and hope for, et cetera, there – then there is a need and there’s a right should have – to have actually humanitarian corridors, that this can happen, that this can take place.

So that will be my few points. And I think, again, I hope next time we discuss – we discuss recovery, we discuss reconstruction. I don’t know how it is going to look. Like, maybe one other argument, I think, for all of us: What will be needed? What’s needed now is flexible support – flexible funding and support for the U.N. and partners to be able to continue to do what they can do.

And why I say flexible? Because the agencies who work in Gaza, it needs to be need-based, as good as possible. We’ve seen a lot of aid which is sometimes maybe not prioritized enough. We can do better at that end, too. And talk – we are now in the middle of a humanitarian phase, et cetera. The recovery and reconstruction will be long term. And I hope that whenever this finishes, Gaza is not going to be forgotten – OK, now the war has stopped; let’s focus on something else. It is going to be a marathon. This needs a marathon exercise for many, many years to come.

Thank you.

Dr. Morrison: Thank you, Rik. Thank you, Rik.

We’re at the end of our hour here. I want to offer my thanks to Lana Wreikat, to Avril Benoît, and to Rik Peeperkorn for joining us today, and for your courage and your commitment in this really awful period. I want to offer my thanks to Michelle Strucke, my colleague here at CSIS; and our colleagues Qi Yu and Eric Ruditskiy, who made this possible; and Sophia Hirshfield, who assiduously put all the pieces together.

I’m taking away, you know, a sense that Washington needs to hear these kinds of very detailed remarks about the gravity of the situation, the spiraling disorder, the level of destruction, the cynicism that’s emerging around the West’s intensions. But also to hear these very concrete things about be careful around airlift and what that may mean, flexible money, medevacs, detentions – addressing the detentions, clearing the roads, and beginning to think ahead around recovery and reconstruction.

It is difficult, in the midst of spiraling disorder and tragedies, to put a focus on that. At times it seems premature. But I agree with Rik that we need to keep our eye on the ball there and begin to hear from Palestinians and others who are thinking about this. I recall working in the Balkans 30 years ago when a key cluster of Bosnians began that process at the – in the depths of the war, in planning. And it proved to be quite impactful.

So with that, I’m going – we’re going to adjourn for today. And I thank our audience for sticking with us for the seventh episode. And we’ll be back soon with another episode. Thank you.