Study shows Gaza death toll is 70% higher than Hamas’ figures

A study published in The Lancet estimates that 64,260 people in Gaza died from traumatic injuries during the first nine months of the conflict with Israel — from October 7, 2023, to June 30. This figure, calculated using a system that cross-references three separate lists, is 69.65% higher than the 37,877 deaths reported for the same period by Gaza’s health authorities, a body under Hamas control. The article suggests that, based on Gaza’s Ministry of Health’s reported death toll through October — now surpassing 46,000 — the total number of fatalities, according to this methodology, could be more than 70,000.

The war began on October 7, 2023, when the Islamist militia Hamas killed 1,200 Israelis and kidnapped 251 hostages. Since that day, Gaza’s Ministry of Health has issued daily reports on fatalities. These figures have sparked controversy, with some critics arguing they are inflated and others claiming they are underestimated. The study ultimately concludes that the official death toll has been underestimated.

The researchers used a system known as “capture-recapture,” which compares overlapping records from three sources: deaths documented in hospitals and morgues by the Ministry of Health, an online survey also managed by the ministry, and obituaries shared on various social media platforms. This technique is widely used to estimate populations when conducting complete counts is impractical or the available data is unreliable.

Study does not include the missing

Epidemiologist Zeina Jamaluddine, a member of the four-person team behind the study, explains that the “capture-recapture” system was initially popularized by conservationists. “They would capture, mark, and release animals or insects in a particular area, then recapture them later and use the overlaps to estimate population sizes.” This method has since been adapted for epidemiological research, including the study of disease prevalence and mortality rates in diverse contexts, including conflict zones.

“The capture-recapture technique,” Jamaluddine explains, “has been applied to estimate mortality in a number of conflict-affected areas, such as Kosovo, Sudan, Guatemala, and Colombia. It allows researchers to estimate the total number of deaths, including those not recorded in any single data source, by analyzing the overlaps among different lists of individuals killed.”

Jamaluddine says that the Ministry of Health in Gaza had statistical systems that were among the most robust in the region prior to the war. “You wouldn’t find anything like that in Syria, even before the civil war. But war inevitably degrades health information systems,” she explains.

The study notes that “escalation of Israeli military ground operations and attacks on health-care facilities severely disrupted” local authorities’ ability to maintain electronic death records. This is what prompted the researchers to undertake a three-month study, which revealed that the Ministry of Health had underestimated deaths by 41% during the first nine months of the invasion.

Two of the datasets the team used originated from the Ministry of Health. When asked if this reliance suggested an over-dependence on Hamas-controlled health authorities, Jamaluddine acknowledged the challenge. “It does. I’m not denying that we used the ministry’s data,” she says. “We relied on records with clearly identified names, and we meticulously cleaned the data by removing duplicates and correcting errors. But to do this correctly, we would have needed to enter Gaza with protection — and that wasn’t possible. International agencies like the United Nations or UNICEF are working in the Gaza Strip, but their focus is on delivering food and medicine. They cannot call people and ask them how many people died in their home, when what they want is food or medicine.”

The study’s conclusions underscore “the urgent need” for “an immediate and sustained cessation of hostilities and a lasting deal that includes the release of Israeli hostages and thousands of Palestinian civilians imprisoned by Israel.”

“Consistent data”

Eduardo Satué, president of the Spanish Society of Public Health and Health Administration (SESPAS), emphasizes that The Lancet’s approach involves examining multiple data sources to assess their consistency. “From the data I have seen, I think they are consistent,” he tells EL PAÍS by phone.

Satué explains that the “capture-recapture” method used in the study is the most reliable option given the circumstances. “It is what we have, there are no more precise alternatives at the moment,” he explains. “Ideally, such studies would be conducted during peacetime, as was done in the 2006 Iraq war, where figures before and after the invasion were compared. Even in peacetime, we saw during the pandemic how challenging it is to fine-tune statistics, for instance, distinguishing between dying from Covid or with Covid. But under the current conditions in Gaza, this method is the best way to do this.”

Satué, a pharmacist by profession, is not surprised that the death toll is higher than that provided directly by the health authorities. “Traditional methods of counting casualties during conflict are based on military reports of those killed in combat, data from hospitals and morgues, and provided by direct observations. However, the latter only enter the official statistics if the identity of the deceased, along with where and how they died, are known. As a result, they tend to underestimate the number of deaths.”

The president of SESPAS highlights that while The Lancet study focuses on direct deaths caused by the conflict, it is crucial to remember that the number of people “who die as a result of indirect consequences of the war is far higher than those who die violently.” These indirect causes include malnutrition, water contamination, lack of health care, he says. “In Gaza, this can have a greater impact than in other conflicts due to the high population density and because it is essentially a kind of prison, which makes providing adequate care much more difficult.”

The Lancet study acknowledges that accurately measuring indirect mortality during an ongoing war poses numerous “challenges and limitations.” Limited access and “highly unsafe conditions for humanitarian and health workers inside Gaza” make such measurements unfeasible.

Satué also notes that his association recently published the third monograph in its series War Conflicts and Their Impact on Health, which examines how these conflicts affect vulnerable groups, including minorities, pregnant women, and children. According to The Lancet, 59% of the deaths in Gaza for which age and sex data were available occurred among women, children, and the elderly — groups that are particularly vulnerable and less likely to be combatants.

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