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A critical analysis of The Lancet’s letter “Counting the Dead in Gaza: Difficult but Essential”. Professor Mike Spagat reviews the claim the total Gaza death toll may reach upwards of 186,000

Recent correspondence ‘Counting the dead in Gaza: difficult but essential’ published in The Lancet by Rasha Khatib, Martin McKee, and Salim Yusuf highlights the importance of documenting mortality in Gaza. 

Their letter noted that, as of June 19, 2024, the Gaza Health Ministry reported 37,396 deaths in the Gaza Strip since the October 2023 attack by Hamas and subsequent Israeli invasion, as per the UN Office for the Coordination of Humanitarian Affairs. The correspondence noted further that the conflict’s indirect health impacts were significant, with the total death toll expected to rise due to damaged healthcare infrastructure, food, water, and shelter shortages, and funding cuts to humanitarian aid. Historical data from conflicts the authors claim to be similar suggest indirect deaths can be three to fifteen times higher than direct deaths. 

Importantly, applying an estimate of four indirect deaths per direct death to the 37,396 reported deaths, Khatib, McKee, and Yusuf suggested that the total death toll could reach 186,000 or higher. This is roughly 7.9% of Gaza’s population. 

Here I argue that the projection of 186,000 total deaths, which comes from multiplying direct (violent) deaths reported by the Gazan Ministry of Health (MoH) by five, lacks a solid foundation and is implausible.

The Basis of Indirect Death Estimates
The authors claim to be “conservative” in applying a ratio of four indirect (non-violent) deaths for each direct death to the official MoH figure of 37,396 deaths. This ratio is plucked from table 2.3 in the Global Burden of Armed Violence report that lists ratios of indirect to direct deaths ranging from 0 to 15.7 for thirteen wars. However, these figures come from a small, non-representative sample of conflicts, many of which differ significantly from Gaza in terms of geography, accessibility, and humanitarian conditions. For instance, Kosovo is included with a ratio of zero, highlighting the variability and context-specific nature of such estimates.

Differences in Conflict Dynamics
Although there are some similarities between Gaza and some of the other conflicts in the table, it is, nevertheless, a unique context. Unlike many of the conflicts in the table, Gaza is a densely populated area with substantial international attention. This focus can potentially mitigate the worst outcomes seen in more isolated conflicts. Despite Israeli restrictions, humanitarian aid efforts continue, and international scrutiny may influence the delivery and effectiveness of aid. The lack of context-specific evidence in the article makes the application of a 4:1 ratio to Gaza speculative at best.

Furthermore, each number in the table from the Global Burden of Armed Violence report is presented with unwarranted certainty. These figures are, in fact, surrounded by considerable uncertainty, as seen in debates over Iraq (2003-2007) and the Democratic Republic of Congo, where ratios have been contested and revised. 

Data Quality and Reporting Issues
The Gaza MoH has faced significant challenges in maintaining data quality. As of April 30, 2024, their fourth detailed list (“list 4”) had several shortcomings, including 1,674 deaths with missing IDs, 829 with incorrect digit numbers, and 1,519 with invalid digit sequences. Additionally, 1,206 entries had missing ages but were still classified demographically. The percentage of women and children among the dead has also varied, highlighting discrepancies between MoH and the Government Media Office (GMO) figures.

UNOCHA’s recent shift in reporting, moving from GMO to MoH data, underscores the need for a consistent and transparent methodology. The GMO’s higher estimates, particularly the claim that 70% of all deaths are women and children, conflict with MoH figures and highlight the need for clarity and accuracy in casualty reporting.

Projecting Future Deaths
It is unclear whether the authors’ claim of 150,000 indirect deaths is a projection for the future or is meant to be something that has already happened. If the latter, then we must ask ourselves why the MoH has reported only direct deaths for months while ignoring the far larger toll of indirect deaths? 

If, on the other hand, this is a projection, then the authors should explain how the thirteen numbers in the table they cite can illuminate how war-related damage to Gazan infrastructure and healthcare will eventually translate into four indirect deaths for every direct one. In fact, a four to one ratio does not even rise to the status of rule of thumb. The true impact will depend on many factors specific to the conflict’s duration, the effectiveness of aid delivery, and the resilience of the affected population.

Historical data from other conflicts should be used cautiously, recognizing the unique factors at play in Gaza. Indirect death estimates must be grounded in the specific context, considering variables such as the availability of medical care, food, water, and shelter.

Recommendations for Accurate Reporting
To improve the accuracy and reliability of death toll estimates, several steps are necessary:

  1. Enhanced Data Collection and Transparency: The MoH should strive for greater transparency in its methodology, bridging the gap between detailed lists and top-line numbers. The ultimate goal should be a comprehensive database that tracks individual deaths with verifiable details.
  2. Independent Verification: Third-party organizations should verify casualty figures to ensure accuracy and impartiality. This could involve cross-referencing MoH data with media and social media reports as the NGO Airwars is doing.
  3. Consistent Reporting Standards: International organizations like UNOCHA should adopt consistent standards for reporting casualties, avoiding discrepancies that undermine the credibility of death toll estimates.
  4. Focus on Individual Victims: Emphasizing individual casualties humanizes the conflict and ensures that each victim is accounted for. Detailed lists, despite their flaws, provide valuable insight into the human cost of war.

While the letter in The Lancet draws attention to the severe human cost in Gaza, its methodology for estimating indirect deaths lacks rigour. Accurate casualty reporting is crucial for understanding the conflict’s impact and guiding humanitarian efforts. By adopting transparent, context-specific methods, we can better document the true scale of suffering and ensure that each victim is appropriately acknowledged. An immediate ceasefire and sustained humanitarian aid remain essential, but so does the integrity of the data we rely on to advocate for these measures.