Christmas thoughts about counting the dead in zones of armed conflict.

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Merijn T. Knibbe
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In those days Caesar Augustus issued a decree that a census should be taken of the entire Roman world. (This was the first census that took place while Quirinius was governor of Syria.) And everyone went to their own town to register.

Luke 1:3 (as will turn out below, this quote is not frivolous)

Summary.

The Gaza Ministery of Health, Airways and the World Health Organization have published robust data sets on victims of war-related violence in Gaza. Médecins Sans Frontières provided the world with a robust qualitative overview of the state of the health system. At the same time, The World Peace Foundation reported on the methodological difficulties of estimating the indirect victims of the war in Gaza. Together, these organisations mention the methodologies that can successfully estimate violent deaths in conflict zones. Information on indirect casualties is still lacking, even when all organizations state that the circumstances, including a planned destruction of the health and social system, are the worst they have seen. This means that ´guesstimates´using indirect methods must be based on a worst-case scenario. Information about worst-case scenarios has to be developed. A total of 350.000 deaths can not be ruled out. Survey methods based on ´their own town or neighbourhood´ instead of households have to be developed to be able to make better assessments of indirect victims of war-related violence.

Introduction

How many people died in Gaza because of the war? We don´t know. Estimating the death toll is not easy. During the last year, much time and effort has been spent counting the dead, using up-to-date methods. Information is, however, still scarce. This blog post lists some methods used to count the dead in conflict zones – an activity necessary to hold the powerful accountable and to commemorate the victims.

May this post be part of this commemoration.

Much attention will be given to Gaza, as many of the methodologies are being applied in Gaza at the time of this writing. But it´s not specifically about this war.

Methodologies of counting the dead in zones of armed conflict.

Who counts the dead in zones of armed conflict, and how do they do it? A number of organizations try to estimate death tolls due to starvation, violence, breakdowns of medical and social systems, and a general increase in mortality in conflict areas. Each of these organizations uses its own, often quite rigorous methods. Below, some of these organizations, their methods, and their results are mentioned. As a review, this overview is incomplete.

• Airwars. According to their website, ´Airwars is a not-for-profit transparency watchdog which tracks, assesses, archives and investigates civilian harm claims in conflict-affected nations´.[1] About their methodology, they state

´For ten years and across eight conflict zones, Airwars has consistently applied the same open-source casualty recording methodology. Each incident of civilian harm is subject to a multi-stage review process. This includes primary language monitoring, in-depth primary language research, multi-stage English-language assessment and review, and geolocation. As such, each incident can take weeks, or even months, to publish´.[2] This methodology takes time, but at this moment, their results for the first month of the Gaza war have been published in their report ´Patterns of harm analysis. Gaza, October 2023´. One of these:

´Over the course of 25 days, Airwars recorded a minimum of 1,900 children killed by Israeli military action in Gaza. This is nearly seven times higher than even the most deadly month for children previously recorded by Airwars´.[3] They have many other results. All of these list Gaza as the worst situation they have investigated.

• The World Peace Foundation.[4] This foundation, existing since 1910, researches the arms trade, African peacemaking, atrocity response, incarceration, and mass starvation. About Gaza, they published ´ How Many People Have Died of Starvation in Gaza?´.[5] Their answer to this question is, at this moment

´We don’t know how many people in Gaza have perished from starvation and related health crisis. But we have good reason to fear that the toll will be high.´[6]

They argue that starvation during wars starvation is often used as a weapon of war. During periods of starvation, many people do not die of malnutrition but of a plethora of frequently infectious diseases. Starvation is not always directly related to these diseases but to the dislocation and breakdown of the social order which often accompanies starvation. This is ´well-established´ knowledge. Uprooting the social order hence often accompanies strategies which use starvation as a weapon of war:

´One important implication of this is that the value of food aid in reducing mortality is not only increasing food consumption but also in enabling people to remain in their homes, preserving their assets, livelihoods and social capital, and minimizing the risk of outbreaks of communicable diseases. Another implication is that attention to water, sanitation, vaccination and other health services is no less important to preventing mortality. All of these lessons are well-established.[7]

According to the report, methods to investigate periods of starvation are protocolized surveys (based upon the protocols of the Standardized Monitoring and Assessment of Relief and Transitions (SMART)), demographic surveys, census data and diagnoses from physicians as well as inference from IPC phases´ (the different stages of a famine), food availability, ratio methods etcetera. A problem with using many of these methods in Gaza is that the scale of the violence, as well as the continuous uprooting of the population, make it hard to compare Gaza with other conflicts and to use ratio- and other methods. The report contains an overview of the use of several of these methods for Gaza by several authors (Table 1 in the report), which shows wildly diverging outcomes:

´Three conclusions can be drawn from this table. The first is that the range of estimates is remarkable. The second is that the low-end estimates can be discounted, and the high-end ones treated with extreme caution. However, figures of 10,000 or more deaths caused by starvation and health crisis/social disruption can be considered a credible estimate of what is occurring. The third is that there is an urgent and imperative need for better data´.

The report also contains a graph comparing Gaza with other conflict areas where starvation was used as a weapon of war (IPC stage 5 is ´the worst´, ´magnitude´ is the number of people at risk and ´severity´ is the percentage of people actually starving). As can be seen, Gaza is at the ´disaster possibility frontier´, to paraphrase an economic term (lines drawn by me).

Figure 1. Rating humanitarian catastrophes, The World Peace Foundation.

Clearly, the situation in Gaza is bad while any solution requires food but also social order and organization.

• The Gaza Ministry of Health (MoH) and ministries of health worldwide have obvious responsibilities regarding tracking the health and related issues of a nation’s population. The MoH famously, for an unexpectedly long period, tracked the number of violent deaths as precisely as possible, which is what it was supposed to do. The Henry Jackson Society (HJS) has failed to debunk these data.[8] The central graph in the HJS report is this one (graph 2).

Figure 2. Population pyramid of fatalities by Age and Sex in Gaza during the Gaza war, according to the Gaza Ministry of Health and tabulated by the Henry Jackson Society.

This graph can be explained as a combination of the two graphs below estimated, using the MoH data on the Gaza war and earlier wars in Gaza by the United Nations.[9]  

Figures 3, 4 and 5. Fatalities of conflicts in Gaza, United Nations.

About the first UN graph: even when males are overrepresented, it closely resembles the population pyramid of Gaza. It is in line with the idea of indiscriminate mass killing caused by the bombing raids.  The other two UN graphs show that killed resistance fighters and others during earlier episodes of resistance are predominantly male (FYI: I do not care about Hamas and do not know why I should). Even when the Gaza MoH data as such do not distinguish between deaths in battle and deaths due to indiscriminate bombing, the pattern is entirely consistent with a situation of simultaneous battle plus indiscriminate bombing. It indicates that even in situations of extreme stress, reliable data on the number of violent deaths can be gathered. One result: many more children and women are killed than during earlier wars. To my knowledge, the Gaza MoH has not published estimates of indirect victims of the war.

• The World Health Organization (WHO). The WHO has estimated the number of severely wounded people using daily reports from medical staff. The daily reports provided information on the kind of injuries inflicted by the hostilities. The Gaza MoH provided data on the total number of wounded (90.000). As about one quarter of the people treated by the WHO teams had ´live changing injuries´ this resulted in a total estimate of 22.500 people with life changing injuries.
• Medicines sans Frontieres. This organization is still active in Gaza despite losing 8 of its employees while many of its employees have been displaced five times or over. In a report on the situation, the systematic, purposeful, planned and violent destruction of the health system is chronicled.[10] This is invaluable input when one wants to use ratio methods – Gaza will know relatively high ratios of sick, wounded and death compared with other conflict areas:

´the actual death toll remains uncertain due to challenges in accurately counting the dead. Hospitals have been destroyed, large parts of the population displaced, bodies are still under the rubble and many deaths go unreported—particularly in northern Gaza, where entire families have been wiped out, leaving no one to identify the deceased. This gap between projected excess deaths and officially reported figures highlights the profound uncertainty surrounding the true scale of the loss.

• Individuals. Individuals also provide invaluable qualitative and quantitative information. According to Virginia Jeffrey, before the war, around 71.000 Gazans diabetics needed insulin, which is very hard to come by.[11]
• Science. Increasingly, scientific studies enable us to use more precise ratios, for instance, about the influence of armed conflict on neonatal mortality and pregnant women.[12] Surveys are used regularly. [13] There is, however, discussion about using surveys to count the dead. I won´t repeat that discussion here.[14] However, the distribution curve of ´deaths per household´ seems irregular because there is no central tendency, large stretches of zeroes, and occasional households with one or more victims. This means one needs clustered populations with vast clusters of very large sub-clusters. Changing the fundamental element of such surveys from ´households´ to ´entire villages-neighbourhoods´ might be necessary. Below, we will use the ´worst case assumptions´ that are consistent with these studies.

This brings us to the citation at the beginning of this post. It might be necessary to gather (virtual) assemblies of people, which enable us to use the memories of these people to recreate the population of entire ´towns´ or neighbourhoods, including families that have been wiped off the earth. The ´Memory of Treblinka Foundation´, to which I recently donated, gathers and publishes names of the people exterminated at this death camp during the Second World War, and for good reason, ´We believe that the deaths of hundreds of thousands of people should not remain anonymous. With each person murdered in Treblinka, their whole universe died – their knowledge, traditions, cus¬toms, faith. We wish to tell people their stories. This is a difficult, extensive and long-term task. We ask everyone who could provide reliable information for assistance´.[15] The methodologies used and experience gained by the ´Memory of Treblinka Foundation can be used to estimate the death toll in Gaza. And to remember.

Wrapping up: dependable information about the number of direct victims and the kind of injuries suffered is available. Information about indirect victims is lacking. Only the vaguest of estimates can, at this moment, be made. Using qualitative information about the situation, these estimates must use ´worst case scenario´ assumptions as all organizations agree that Gaza is the worst they have witnessed. Assuming a 30% death rate of diabetics and a 15% death rate for newborns and infants up to 2 years (at the moment of writing), this plus a 3% death rate for women giving birth would add roughly 21.000, 20.000 and 3.000 victims for just these groups. Taking a macro approach, based on the methodology used in The Lancet, would lead to somewhere between 200.000 and 300.000 indirect victims as of today. Adding this to the victims of the violence, including roughly 10.000 under the rubble or eaten by stray dogs, leads to an estimate of at least 350.000 deaths. Survey-based research to estimate the number of victims is possible but should to be based on households but on a sample of entire neighbourhoods. A virtual registration of survivors in their own town is possible and can be used to write down the names of the missing.

[1] https://airwars.org/about/ assessed December 19, 2024.

[2] Airways, Patterns of harm analysis, October 2023. P3. https://gaza-patterns-harm.airwars.org/ assessed December 19, 2024.

[3] Other episodes in conflict zones were the Battle of Raqqa, the Battle of Mosul, Syria 2016 (all actors), the US and allies campaign against ISIS in Iraq and Syria, Civilian casualties from Russian support to the Syrian Regime since 2015, Civilian casualties during the ‘Battle of Kharkiv’, the 2011 NATO campaign in Libya, the ensuing civil war with foreign intervention in Libya from 2012, US military and CIA operations in Yemen, Turkish actions in northern Syria and Iraq against Kurdish forces and factions, and the US campaign against al-Shabaab in Somalia. In May 2021, Airwars teams documented all civilian casualties in Israel and the Gaza Strip during the ten-day war.

[4] https://worldpeacefoundation.org/our-story/

[5] To be found at https://worldpeacefoundation.org/blog/how-many-people-have-died-of-starvation-in-gaza/ December 17, 2024

[6] Ibidem

[7] Ibidem

[8] Henry Jackson Society, Questionable Counting: Analysing the Death Toll from the Hamas-Run Ministry of Health in Gaza. December 13, 2024. https://henryjacksonsociety.org/publications/questionable-counting/ Assessed December 19, 2024. This report mistakenly mentions 5.000 natural deaths in Gaza per year. Taking the death rate of 0,0291 per 1.000 people and a population of pre-war population of 2.300.000, the number of natural deaths will be over 6.000.  https://en.wikipedia.org/wiki/Demographics_of_the_State_of_Palestine. The Ministry of Health data are generally considered to be dependable by a whole score of organizations, including the Israeli army. https://en.wikipedia.org/wiki/Gaza_Health_Ministry

[9] https://www.ohchr.org/sites/default/files/documents/countries/opt/20241106-Gaza-Update-Report-OPT.pdf assessed December 20, 2024.

[10] Medicines sans Frontieres, Gaza Life in a Death Trap https://www.artsenzondergrenzen.nl/documents/249/Rapport_Gaza_december_2024_-_Artsen_zonder_Grenzen.pdf December 19, 2024.

[11] Virginia Jeffries, ´Gaza´s insulin crisis. How diabetics are fighting to survive´, Newsweek magazine June 24, 2024  https://www.newsweek.com/2024/08/09/israel-hamas-war-gaza-insulin-diabetes-health-1928439.html

[12] Mohammed Jawad , Thomas Hone, Eszter P. Vamos, Valeria Cetorelli and Christopher Millett ´Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000–2019´, PLOS medicine September 28, 2021. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003810

[13] Catherine R. McGowan, Mervat Alhaffar, Promise Ekoriko, Sawsan Al-Refai, Jamal Badr, Lucy Bell & Francesco Checchi, ´Adult mortality patterns in Yemen before and during armed conflict: evidence from a web survey of the global diaspora´, Conflict and Health volume 17, Article number: 36 (2023). https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-023-00535-8. See also Rasha Khatiba, Martin McKeec and Salim Yusuf Volume 404, Counting the dead in Gaza: difficult but essential, The Lancet issue 10449 237-238 July 20, 2024, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01169-3/fulltext and Ingrid De Zwarte, Peter Ekamper, L H Lumey ´Infant and child mortality in the Netherlands 1935-47 and changes related to the Dutch famine of 1944-45: A population-based analysis´. Population Studies 78(3):483-501 and Mohammed Jawad, Thomas Hone, Eszter P. Vamos, Valeria Cetorelli, Christopher Millett ´Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000–2019´. September 28, 2021. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003810

[15] https://memoryoftreblinka.org/the-names-of-the-victims/ assessed December 21 2024.

[14] https://en.wikipedia.org/wiki/Lancet_surveys_of_Iraq_War_casualties