Senator Van Hollen on Next Steps in Gaza

This transcript is from a CSIS event hosted on March 13, 2024. Watch the full video here.

J. Stephen Morrison: Welcome to this eighth episode of Gaza: The Human Toll, “Three Futures for Gaza,” a broadcast series started in November by the CSIS Bipartisan Alliance for Global Health Security in partnership with our colleagues here at CSIS, the CSIS Humanitarian Agenda and the CSIS Middle Eastern Program. I’m J. Stephen Morrison, senior vice president here at CSIS.

I’m delighted to be joined today by two distinguished guests who have contributed significantly to our understanding of the rapidly evolving humanitarian crisis in Gaza. I want to offer a special thanks to these two guests: Senator Chris Van Hollen – I’ll introduce him in a moment – Democrat of Maryland; and Professor Francesco Checchi of the London School of Hygiene and Tropical Medicine.

I’m joined by my colleague here today, Michelle Strucke, director of the CSIS Humanitarian Agenda, and director of the CSIS Human Rights Project, and former deputy assistant secretary at the Department of Defense on global partnerships – issues that we’ll be touching on quite a bit today. I want to offer a special thanks to Sofia Hirshfield, who worked tirelessly – my colleague – who worked tirelessly to pull this all together; and to our production staff, Eric Ruditskiy and Dwayne Gladden; and to Paul Spiegel at Johns Hopkins University, who partnered with Francesco; and to Senator Hollen’s staff.

The first half-hour of this hourlong broadcast we’ll hear from Senator Chris Hollen, a member of the Senate since 2016, served in the House from 2002 to 2016, representing Maryland’s Eighth Congressional District. His committee assignments in the Senate include Appropriations, Foreign Relations, Banking, Housing, Urban Affairs, and Budget. The second half we’ll hear from Professor Francesco Checchi. I’ll introduce him at that time.

Senator Hollen, I’ve read over your many statements dating back to early in the Hamas-Israel war. And it’s quite remarkable, your leadership and the impact that you’ve had. You’ve led the way in developing the argument that the Biden administration needs to use U.S. leverage and U.S. law to insist that Israel allow in more aid and be in compliance with international humanitarian law, while pressing for an immediate ceasefire and release of all hostages. You put a special focus on the transfer – the transfer of U.S. military assistance to Israel, calling for oversight, accountability, a level of conditionality, and expressed very openly your worry about complicity and damage to U.S. national interests.

You conducted a trip in early January with Senator Merkley to Jordan and Egypt, visited in Egypt Al Arish and Rafah gates, and made very specific recommendations on expanding border crossings, on streamlining inspection process, on putting in place a deconfliction mechanism, on restarting commercial traffic, and opening maritime and air routes with U.S. military assets. You introduced an amendment in the Senate to the National Security Act of 2024 in early February, and worked closely with the Biden administration in developing the National Security Memo 20, which was issued right after the introduction of that amendment, calling for ensuring that U.S. aid – military aid is in accordance with international humanitarian law, assure cooperation with U.S.-supported humanitarian efforts, and requiring robust reporting to Congress. We’ll be hearing some of that reporting at the end of March.

You were very – made very strong statements after the tragedy on February 29th in Gaza City. And we’ve seen the significant impact in terms of the president’s State of the Union address and subsequent statements. But we know that we’re still in a roiling crisis. We know that fundamentally access remains exceedingly limited. Malnutrition is worsening. The threat of famine is hanging over everything.

In your view, what more needs to happen now? You’ve staked out this framework. You’ve developed it. You’ve had huge impact. But we still have a really harrowing challenge in front of us. What, in your view, needs to happen next?

Senator Chris Van Hollen (D-MD): Well, Stephen, it’s good to be with you and Michelle. And thank you to CSIS. And you provided a very important overview there.

I would just add to that that we all witnessed the horror of October 7th and the 1,200 people who were killed. I met just yesterday with the hostages’ families, a number of the hostages’ families. And on the other side of the equation, of course, you have the terrible humanitarian situation in Gaza.

And I have said repeatedly that Israel was justified in self-defense, but that does not justify the current horrendous humanitarian conditions in Gaza, which are manmade, and as you just went through some of them, which is exactly why I visited Rafah and why 25 senators wrote to President Biden way back in early February laying out five changes that need to be made in the delivery system.

Ultimately, of course, the only way to end the suffering all around is the ceasefire and the release of hostages. But at this moment, while I support the airdrops, they’re also a drop in the bucket. I support the idea of a temporary port, but this will be at least six weeks in the making and still not sufficient for delivering the kind of aid that’s necessary to address starvation in Gaza. And we know that kids have literally died of starvation.

And that is why we have to continue to use more levers of U.S. influence to insist that the Netanyahu government open the Erez Crossing in the north. This is where you have the highest degree of starvation and people dying. This is an area currently totally under the control of the IDF. And that needs to be opened immediately. And the president, President Biden, needs to insist that that happen.

Deconfliction within Gaza is really important. Deconfliction is just a word to say that we have to make sure that aid workers can be able to deliver aid to people who are starving and in desperate need without themselves getting killed. There have been lots of aid workers who have been killed delivering aid. Some of the police escorts for some of the convoys were targeted by the IDF. We also know of a, you know, offshore ship missile that hit a convoy that had been cleared.

So this is not totally rocket science. I mean, when you talk to NGOs that have operated, you know, worldwide for decades, they say, number one, they’ve never seen a worse humanitarian crisis, and, number two, they’ve never seen a more broken deconfliction process.

And finally – and this is continuing to happen – when I was in Rafah, I went to a warehouse full of items that had been rejected by the inspectors, the Israeli inspectors, at Kerem Shalom. And the rejected items included things like maternity kits, water purifiers. Some of them were solar-powered, you know, mechanisms to help purify water, contaminated water.

And there was no rational justification for why all these items had been rejected. Supposedly they were rejected because they were dual-use, that they could be used as weapons. There was never any explanation for why some of these items were rejected. So, for example, a maternity kit has a teeny little scalpel in it. So we speculate maybe that was the reason. But it’s important to understand that when one item on one of these trucks is rejected and turned back the entire truck is turned back around and has to get back in line, which can take weeks and weeks – at some points up to four or five weeks – to go through the entire process again.

So, look, again, ultimately, the only way to resolve this is ceasefire and return of the hostages. That’s what we should be doing right now. But in the meantime the president does have to use more levers of influence and to insist that these humanitarian changes take place so that we can help people who are literally starving to death.

Dr. Morrison: Thank you.

You’ve been pressing for conditionality. We will see the report to Congress by March 24th or 25th under the current policy. Two questions. When the president was asked most recently is there a red line or not on Rafah, meaning will we – if there is a siege of Rafah will we impose conditionality. That’s a very ambiguous – that’s a very ambiguous question right now in terms of where the administration really stands on that matter. What is your view in terms of conditionality of military assistance today and what is your – what do you expect in terms of the consequences of the reporting to Congress?

Sen. Van Hollen: Well, let me start with National Security Memorandum No. 20. This is – as you described, this is something that I pushed for.

It came in the aftermath of 19 senators joining my amendment that would establish clear rules for the delivery of any U.S. military assistance to any country including Israel, Ukraine, and others, and one of those provisions said that every country receiving U.S. military assistance must agree up front and in writing to facilitate and to not arbitrarily deny or restrict the delivery of U.S.-supported humanitarian assistance.

The deadline for getting those commitments signed for countries that are currently in conflict, so that includes Israel, is March 24th and if the assurances are not there by then and they’re not credible assurances then the president is supposed to impose, you know, sanctions, penalties, including the non-delivery of U.S. weapons for use in Gaza, among other things.

I should say, Stephen, that this does not include Iron Dome and defense systems but it does include bombs and offensive systems. So that is a very important mechanism and it’s really going to be essential that the Biden administration use that important leverage and tool.

On the Rafah issue, as the president himself said that it was a red line. In other words, Netanyahu and his government have been saying that they’re going to go into Rafah. President Biden said that would be a huge mistake and a red line, and it’s my view that when the president of the United States, you know, draws a red line the president needs to ensure that there’s an enforcement mechanism. Otherwise, you look, you know, feckless.

I mean, if Prime Minister Netanyahu just ignores the president of the United States after the president has said that that’s a red line then it just undermines our effectiveness overall.

And so, yes, I have said, and Senator Schatz and myself and Heinrich and Luján wrote a letter to the president some time ago, almost three weeks ago now, saying that if the Netanyahu government decides to go into Rafah if they don’t open up more of these crossings and allow more humanitarian aid in then we will use our powers and ability to stand in the way of future weapons deliveries to the Netanyahu government being used in Gaza.

And there are different mechanisms for doing that. The president and the administration have to report to Congress. They’re supposed to, anyway, provide notice when they’re actually transferring weapons so there’s an opportunity for Congress to weigh in at that time.

So we are trying to use all the mechanisms we have to get the president and the Biden administration to effectively use the ones that they have.

Dr. Morrison: Thank you.

Michelle, would you care to join in now?

Michelle Strucke: Yeah. Thank you. And thank you so much, Senator Van Hollen, for your extremely important voice and work on these issues.

I’m curious to hear, if I could ask one question of you, about your thoughts on the waiver provision. Since in the NSM-20 – and we know that waivers have been used historically for really important U.S. government allies by the president, or by the secretary of state, or secretary of defense, to be able to get around some of these really important human rights legal provisions and humanitarian access provisions. So the NSM-20 does have a waiver. I know it doesn’t limit the congressional reporting, but it does, I believe, limit the ability to actually provide those credible and reliable written assurances. So do you have any sense of whether the administration has told Congress that they plan to exercise that waiver?

Sen. Van Hollen: They have said nothing about any plan to exercise the waiver. And, you know, this was discussed, you know, thoroughly during the negotiations over NSM-20. It is very, very narrowly drawn and has to be time limited. So I actually do not expect, you know, the president exercise this waiver in in the case of what’s happening in Gaza. The NSM-20, as you know, is now a global policy. So it had to anticipate, you know, global events that could happen. And so there’s a very narrowly drawn waiver.

I will also point out that if the president exercises that waiver, the president has to very quickly notify the Congress. And so I think it would be very difficult for the president and the administration in this case to say that, for example, the Netanyahu government had violated the terms of the NSM after signing these commitments to use U.S. weapons in a manner consistent with international law, to make sure that we have humanitarian access. I think it would be very difficult for the president to say that those promises have been violated, but that the president is going to waive them. I do not anticipate that happening.

Ms. Strucke: Well, thank you. That’s assuring to hear, I think, for our audience as well, because the – there’s some important context I wanted to share as well with the – with our viewers. Which is that, you know, the U.S. Defense Department a few years ago initiated a really historic reform effort on civilian harm, broadening the kind of traditional concept of civilian casualties and sort of the legally required unit-by-unit and kind of strike-by-strike analysis, that, you know, the U.S. military uses – and partner militaries. They’re looking at partner militaries, how they do this – analyze whether kind of undue or excess civilian harm would be caused by their work. It also kind of broadened that definition so that the U.S. government recognized that civilian harm doesn’t – it affects all civilian infrastructure, it affects the lifeblood of civilian institutions – hospitals, schools, et cetera.

And so in the context of this war and the U.S. military support to this war, you know, there’s definitely been very concerning behavior, and with, you know, high-level officials in the U.S. government themselves calling attacks “indiscriminate.” And I understand that these provisions, these global provisions like the National Security Memorandum No. 20, the CAT policy, and other kind of global U.S. government policies indicate that, you know, violations of international humanitarian law – like attacking civilians indiscriminately – would be something that would – should, anyway. cause the administration to look at their military support.

I want to also just highlight how important it is that you, Senator, and the administration, after your urging, has introduced this important link, which is reflected in U.S. law. But it was worth highlighting that humanitarian access and of U.S. humanitarian assistance with the U.S. partners, that you mentioned, that that is not something that can continue to be compromised. It’s an essential requirement of humanitarian law that that Israel allow in humanitarian assistance. It’s a bare minimum. It’s a lifeline. And it’s U.S. partners at stake. And I know many of those, Senator, are probably your constituents that are organizations that are risking their lives to serve the population that are suffering in Gaza. So thank you for your efforts. And I think it’s really important that humanitarian access, which is really incredibly restricted and denied right now, particularly in the north of Gaza, is highlighted.

The last point that I will make on this is that you know, considering the situation right now – with Ramadan, the lack of a ceasefire, and people who are really facing, really, unprecedented starvation at the moment in Gaza, as we’ve talked about on prior episodes – it’s such an important moment around the world stage, with people looking at this situation as, you know, more than – almost a billion Muslims around the world are fasting during the day in a way where they’re attempting to imagine the suffering and the – and the food insecurity of other people. This is a real spotlight moment on Gaza that I think is important for people to recognize is going to be a powerful motivator for regional governments as they think about what they are doing.

So thank you again. I think this is – these are really important points. And unfortunately, I think that while the U.S. government, including my former colleagues at the Department of Defense, are doing absolutely heroic things – tying themselves in knots working to do things like create the pier, which as you mentioned will take weeks; and to deliver these, as you mentioned, drop-in-a-bucket airdrops – it’s nowhere near a replacement for opening the border crossing that you mentioned, creating an environment where Israel is discharging its responsibility to facilitate and allow that unfettered access of humanitarian aid. And it’s certainly – if the U.S. does not use its levers for conditioning military assistance, it really does seem, as Elizabeth – Senator Elizabeth Warren said, like, the U.S. Congress is giving a blank check to Israel during a context in which U.S. important policies like the civilian harm reform effort are really being undermined. And that’s going to have an impact on the U.S. strategic interests in the future with other conflicts, not just this one.

Dr. Morrison: Thank you, Michelle.

Senator?

Sen. Van Hollen: Well, let me just amplify on a couple things Michelle said. And, Michelle, thank you for the work you did when you were at the Defense Department on these issues.

First, let me say with respect to the reporting requirements in NSM-20, they are very comprehensive and the reporting requirements are sometimes overlooked. But this is a critical part of the accountability mechanism because the reporting requirements cover the entire period, all of last year up to now, so cover the entire period of the war in Gaza and, of course, much of the war in Ukraine. But they require not only reporting on whether not the Netanyahu government during the prosecution of the war in Gaza has complied with international law.

They also require that the – the report also has to include whether or not they abided by best practices for reducing civilian harm, which is a different standard and one in which, when you talk to sort of U.S. defense analysts, they’re quite unequivocal about the fact that the way the war is conducted – been conducted in Gaza does not meet the best practices that the U.S. has established for reducing civilian harm. The United States is not perfect by any means, but we have put in place these mechanisms to reduce civilian harm in conflict. And the report will require information on the extent to which Israel has been complying with those best practices.

In terms of the humanitarian assistance piece, look, we all know that this is a manmade crisis. I mean, we have starvation in certain parts of the world because of climate disasters and all sorts of other factors. In this case, it is the restriction of the delivery, both getting into Gaza and within Gaza, of humanitarian assistance. And the National Security Memorandum 20 requirement on facilitating humanitarian aid is broader than current law.

And I do want to say something about current law because a group of us – about eight of us just sent a letter to the president just the other day stating that we thought that the United States is already not implementing current law. So there’s a law on the books. It’s called the Humanitarian Aid Corridor Act. It’s Section 620(i) of the Foreign Assistance Act, which says that the United States shall not provide security assistance to any country that is, you know, currently prohibiting or otherwise restricting, directly or indirectly, the delivery of assistance. We believe that the Netanyahu government is already in violation of that provision and that the Biden administration should have been applying that law – which, by the way, would not restrict transfers of Iron Dome and defense systems.

But I’m laying that round because, later this month, the government – the Netanyahu government and other governments are going to have to sign these commitments regarding humanitarian aid. And the requirements for delivering humanitarian aid under the NSM-20 are more expansive. They’re broader than the current law. So we believe the current law has already been triggered and needs to be implemented. But if the Biden administration has a different point of view on that part of it, it is really, in my view, very clear and unambiguous that currently the Netanyahu is in violation of the requirements on NSM-20. And they’re going to have to sign up to commit to those by March 24th.

Dr. Morrison: Thank you.

Senator, we have just a few minutes remaining. I want to ask you two specific questions. Len Rubenstein of Johns Hopkins University, he and I have been writing a piece on accountability by Israel that will be published later this week. And one of the points that we make in this is that there’s a record of Israel consistently, over the course of this war, denigrating the U.N., U.N. agencies, including UNRWA, the U.N. Relief and Works Agency for Palestinian Refugees; but also denigrating the international NGOs – MSF, international organizations like the International Committee of the Red Cross, Palestinian NGOs.

What – the two questions. One is, what more can be done to cease that pattern? Because it is one that creates an environment of open hostility and insecurity and intimidation. And secondly, what’s your thoughts on restoring American commitments to UNRWA? There is an ongoing investigation. We’re expecting some interim reports on that this month. But if you could speak to those two issues before we run out of time, I’d appreciate it.

Sen. Van Hollen: Well, I’m really glad that you raise that. And you’re right. UNRWA has been a particular target of the Netanyahu government’s rhetorical attacks. And the first thing to keep in mind here is that, you know, Prime Minister Netanyahu has been trying to eliminate UNRWA since as far back as, you know, 2017. I mean, there’s a long history of his comments saying he wanted to dismantle UNRWA. He doesn’t like the fact that there’s a U.N. agency that was set up to serve Palestinian refugees. And, of course, UNRWA operates not only in Gaza but in the West Bank, in Jordan, in Lebanon and in Syria. One of the main things they do is provide schools for kids.

So let’s now zero in on the situation in Gaza. UNRWA has 13,000 people working for it. Every single one of the names of people who are part of UNRWA have been given to the government of Israel, as well as the government of the United States, for as long as they’re operating. So they’ve been in full view and transparent, transparent in terms of the name. So any time the United States or the government of Israel wanted to say, hey, we think one of these UNRWA individuals is a danger, they’ve been free to do it for years. In the case of Israel, my information is they’ve never raised that issue. And in the case of the United States, there have been a few occasions.

Now, we have seen these very serious allegations by the government of Israel saying that up to 14 members of UNRWA in Gaza – which is, again, a 13,000-person organization – that up to 14 of them participated in the horrific October 7th attacks. So, yes, if that happened, then those individuals should be held fully accountable. And UNRWA has said so. But we should not, as a result of the terrible acts of 14 people, alleged, punish 2.2 million Palestinian civilians in Gaza by cutting off support for the main delivery system, the primary delivery system of humanitarian assistance within Gaza. Right now, in Gaza, of course, UNRWA is not operating the schools they normally do for the kids, because there’s a war on. What they are doing is being the primary delivery system for aid when it gets into Gaza. And if you – if you dismantle that, if you defund that, you’re cutting off the very little lifeline and pipeline that that exists.

I would also point out that if the argument for, you know, at least temporarily not providing UNRWA Gaza with support is the allegations against these 14 people, that still doesn’t explain why they want to cut off funding for UNRWA in the West Bank, Jordan, and other places, right? So what this really does point to, Stephen, is the fact that this has been a longtime objective of Netanyahu, to dismantle UNRWA across the board. And I really call upon the Biden administration to vigorously defend the actions – to defend the need for UNRWA to operate in Gaza for humanitarian reasons, and to operate in other areas.

I’ll tell you, if you defund UNRWA in the West Bank, you’re going to create even more instability in what is already a terrible situation there. We haven’t talked about the West Bank, but defunding UNRWA and closing the schools there would be devastating and create a lot of instability. And the same is true in Jordan, and other places. So I’m glad you raised this. There’s a concerted effort by the Netanyahu government to demonize UNRWA, when in fact they’re providing really important humanitarian assistance in Gaza right now, and support to Palestinian students elsewhere in the region.

Dr. Morrison: Thank you, Senator. We want to be respectful of your time. I would – this is a very difficult – obviously a very difficult and complicated issue, involving populations – Israelis and Palestinians – that have been deeply traumatized in this period. We are in a period of flux in U.S. policy. We’re in a period of galloping famine and threat of a dramatically worsening situation. Where do you see hope in this picture? Just to close on this. I want to close on a more positive note. Where do you see hope? And where do you find optimism in this – in this terrible situation, Senator?

Sen. Van Hollen: Well, you’re right. It is an ongoing, desperate situation. Of course, we do need to meet the immediate needs of people who are literally starving to death. I think President Biden has tried to lay out the path to some light at the end of this very dark tunnel. And that is to move forward with a two-state solution, which has been, you know, U.S. policy now for a very long time. I mean, formally articulated in the early 2000s by, you know, President George W. Bush. But we’ve never matched our rhetoric with action. But, you know, the only way to address the fundamental issues here is to ensure that Israelis can live in security, but that Palestinians can also live in in dignity, and security, and have self-determination in a Palestinian state.

And so getting there, in my view, has to be the imperative as we – when we end this war, which we should do sooner rather than later, and release the hostages. But that’s the way forward. Now, of course, you know, Prime Minister Netanyahu has openly rejected President Biden’s calls for a two-state solution. So this is going to be a big challenge. But there is a lot in it to ensure that Palestinians have dignity going forward, but also that Israelis have security. Because part of this agreement would also include a normalization of relations between Saudi Arabia and Israel, and other Arab countries and Israel – Arab countries that are the ones that have not yet recognized Israel. So this is the only way forward. But, again, you have President – excuse me – you have Prime Minister Netanyahu at least currently, you know, standing in the way of this. And so President Biden is going to have to, in my view, really put forward a vision for how we build, how we light a little bit of light at the end of the tunnel.

So I do have to run now. Thank you for what you’re doing and I look forward to, you know, following your continuing episodes.

Dr. Morrison: Thank you so much, Senator. This is very generous of you, and we’ll remain in touch. And thank you to your terrific staff for helping us both pull this all together today and we’re very grateful.

So we’re now going to transition to hear from Professor Francesco Checchi. I’m going to bring him on. Hi, Francesco.

Francesco Checchi: Hi. Good morning.

Dr. Morrison: Good morning, and thank you so much for joining us.

Francesco Checchi is professor of epidemiology and international health at the London School of Hygiene and Tropical Medicine. He’s a specialist in quantitative public health measurement and disease control in crisis settings, whether that’s war related, natural disasters, epidemics. He was the lead investigator for the joint study that was published February 19th “Crisis in Gaza: Scenario-Based Health Impact Projections” between – the projections between February 7th and August 6th of this year, published 19th of February.

Congratulations to you, Francesco, and Paul Spiegel and the teams at the two great universities that you represent on putting this story – this report out. It drew very strong media interest. It provides an important new tool for decision.

It was focused on excess mortality. This dimension, as Francesco will explain, is terribly important in trying to understand what has happened up to now and what may lie ahead. This is a conflict where many people have made the profound remark that this is a place where the 2.2 million Palestinians have no escape route. This is a place where there has been huge displacement but getting out of harm’s way has not been one of the options.

Francesco and his team prepared three scenarios for the next six months and raised – and asked the questions what would happen in terms of excess mortality under a ceasefire, under a status quo – a continuation of the current situation – and under an escalation of the war, which I assume would include the siege of Rafah.

They use projections that are without epidemics and ones that are made if there is an epidemic outbreak of infectious diseases, which many have been predicting would happen and we – there are many, many important points embedded within those three scenarios.

So I’m going to turn it over to Professor Checchi and ask him to take a few minutes and walk us through the report and then we’ll have a conversation with Michelle Strucke and myself around teasing out what some of the implications of all of this important work are.

So thank you for joining us, Francesco. It’s great to have you with us. Congratulations on the report. Very impactful, drawn enormous attention. So over to you to walk us through it.

Prof. Checchi: Thank you. Thank you so much, Steve, and I do want to acknowledge all of my co-authors that were involved in this project including Zeina Jamaluddine, who is the lead author, and Paul Spiegel – you already cited earlier – at Johns Hopkins.

I do have a few slides to show so I think I can go ahead and run those – run through those with you guys. OK. Here we go. Let me just maximize. Hopefully, you can see my slides.

So the first thing to say is that we have a website – here’s the web link – and an email if you want to write to us. We really insisted from the very start on making our work quite transparent, so we not only have a report and summaries in Arabic and Hebrew, we also have a very detailed methods annex. And all of our data and analysis code are also up there, so that people can actually, if they so wish, replicate what they have done – what we have done, and critique it, obviously.

Now, you have already laid out sort of the main sort of framework of the project, and the three scenarios. So I will just go ahead and run you guys through the headline findings. It’s, firstly, worth noting that we started our projection period on the seventh of February. So we’re already a month into that projection period of six months. Now, we did in fact compute our best estimates of how many people died in excess of the pre-crisis level from 7th of October to 6th of February. So what we call the “period to date” on the slide. And it’s worth noting that our estimates are that something on the order of 40,000 people already had died by the time our projection started, in excess of the norm.

Then we have the projections. And these, as you laid out, Steve, are according to the three scenarios that you presented. And there, the difference is very, very stark. So that by the – by early August, when our projection period ends, we could be looking at, in addition to these 40,000, another 85,000, in an escalation scenario, versus something like 11,000 in a ceasefire scenario. Perhaps one thing – one way of looking at these results and taking something positive out of them, perhaps, is that the difference between a ceasefire and the most pessimistic option here is really remarkable. And that is, in a sense, the scale of mortality that can actually be averted if indeed we are able to reach a permanent cessation of hostilities.

Now, I’m going to run you through some of the findings that relate to specific causes of death, because we actually divided our work into all the main reasons why people would die in Gaza. The first and really dominant cause of death that we looked at was traumatic injuries due to aerial bombardment or ground warfare. And here – and we think that in our projections this would continue to be the main reason why people are dying. What you’re actually seeing is our projections here are broken down into the first three months and the second three months of the period. And then you’ve got each of the columns representing the different scenarios.

There would still be some injury, mortality in the ceasefire scenario because of people who were injured during the war and die later on of their wounds, because of exposure to unexploded ordnance. But, of course, you know, the levels of injury and mortality would be far higher in the status quo and escalation scenarios. And what we’re actually showing here is also, in the darker color, how many people we think would die of their wounds. And that actually is important because it represents potentially avertable mortality, if one can actually substantially improve availability and quality of emergency surgical services.

It’s also worth noting – and this has been really shown by others – that when you look at the age, sex distribution of people who are projected to die of traumatic injury, these are colored bars on this graph where we’ve got age on the y axis and the two sexes in different colors. And essentially, the distribution of people who are dying of injury is very similar to the overall age, sex distribution of the population of Gaza, which is shown here in the hollow bars with borders. So what this is saying is that essentially there is a widespread risk of dying from traumatic injury that doesn’t just affect males of combatant age. Yes, you can see that these are slightly overrepresented, but essentially we’re seeing a large number of children, women, people of noncombatant demographic characteristics being affected by injury mortality, and injuries of course. And you can imagine, you know, hundreds of thousands of people probably having to live with debilitating injuries for their life.

We also looked at malnutrition. And what I’m showing here, which I think we will return to in the discussion, is the number of trucks containing food that have entered Gaza until the start of our projection period compared to, on the top of this slide, the level that would have entered Gaza before the war. Now, what we did is we used a variety of models to convert this into projections of the prevalence, or rate if you like, of global and severe acute malnutrition among children. Children, as we know, are the most vulnerable group when it comes to malnutrition, and I think the projections here are really very sobering. We are potentially going to see rates of acute malnutrition that I personally have not seen at the population level in other crises that I’ve been involved in throughout the world in the last 20 years. And this would happen in an escalation scenario, but I think, as we can discuss later, I’m afraid we are very much along the lines of the escalation scenario when it comes to nutrition.

Just quickly running through some of our other results, the risk of pandemics. We think the main threats there would be cholera, measles, meningitis, and polio. Luckily, there was very high vaccination coverage in Gaza before the war that to some extent is protecting people, and children in particular – but only to some extent, of course. Cholera is not currently circulating in Gaza, but if it were introduced then we would project potentially devastating epidemics with up to hundreds of thousands of fatalities.

We looked at maternal and newborn deaths, as well as stillbirths. And whilst the numbers here are relatively smaller than what I have shown far, it is extremely important to note that, at least for an epidemiologist like myself, the death of a mother or a newborn counts disproportionately because of its effects on the family, because of all of the years of healthy life that are lost as a result. Essentially, what we are seeing is that Gaza risks returning or is, in fact, returning to levels of maternal and neonatal mortality that were being measured about 20 years ago in the Gaza Strip, so 10, 20 years of progress undone, unfortunately.

We looked at noncommunicable diseases, chronic diseases. This was probably the hardest part of our analysis, and, actually, here there are some omissions. We were simply unable to find sufficient data to parameterize some of the models, for diabetes type two for example. So it’s a major omission, if you like, in terms of what we’re showing here. But we did capture heart disease, which remains – which was the main cause of mortality in Gaza before the war and is going to contribute, you know, at least a thousand and probably more excess deaths because of all the reasons that you can imagine – people no longer being on medication, people not being able to access quality care when they have a stroke. And you can see the other diseases that we looked at here – diabetes type one, right, so, so reliant on sustained supply of insulin; chronic kidney disease, so reliant on people being able to access dialysis. You may know that in Gaza before the war many cancer patients – albeit with a delay due to administrative permits that were sometimes not given, many cancer patients would go get treatment – chemotherapy and radiotherapy in Israel or West Bank, and that’s no longer happening. So, again, a lot of excess mortality due to – due to that.

Lastly, mental health. We didn’t look at mental health. We plan on doing that as we move forward with our work. But it is worth noting that Gaza already had prevalences of anxiety and depression that were personally higher than I can think of anywhere else because essentially – somebody else was pointing out the other day – a 16-year-old child in Gaza has already gone through six wars. Now we are layering on top of that the extensive trauma due to this war. And we know, of course, that mental health has multiple interactions with physical health, and all other aspects of human functioning. That, I think, we will try to explore in future iterations of this work.

I’m going to stop here and probably stop sharing my slides, if that’s OK, Steve, because we probably need some time for discussion.

Dr. Morrison: Thank you. Thank you so much, Francesco. That was – that was terrific.

Before, when we were having a discussion, a couple of – a couple of very important points surfaced that I’d like to just put on the table. One is that this study is a pretty dramatic – in a positive light – is a pretty dramatic argument for a ceasefire. The difference between status quo and ceasefire in the next six months is up to 54,000 lives saved by ceasefire. And if it’s – and if you’re comparing it to an escalation, it’s even higher – by a factor of maybe 30,000, 27,000 more. So the value in human lives of ceasefire is vast. And that’s embedded in this argument that you’re presenting.

A second thing is that you have put the human reality and the human lives at the center of what should be a decision process about which way we go. And that’s enormously profound and important in trying to shape decision-making in this period. You rightfully say that nutrition is emerging as an escalatory driver, and maybe even in the course of your own analysis we may not have fully – you may not have fully appreciated the degree to which it is galloping forward as a driver.

Prof. Checchi: Yeah.

Dr. Morrison: The other things I wanted to emphasize is, even with a ceasefire rising mortality does not cease. You will still have up to 12,000 excess deaths in the next six months if you had a ceasefire that started February 7th. Why is that? And you can explain, but I’m assuming it’s because the situation is so deteriorated, the siege has had such impacts on lives, on the health – on the condition of the health sector, on the condition of the population, that you cannot stop that momentum entirely with a ceasefire. So you have to build into your thinking that you’re going to have – you’re going to go from 40(,000) to 52,000 deaths, surplus deaths, excess deaths. That’s very important. You need to prepare for that.

The other thing I’d say is the status quo adds – the status quo – if we just continue in the current situation of no peace and continued war at current levels, we’re looking at adding up to 66,000 deaths. And we’re pushing it close to 5 percent of this population of 2.2 million having died. That is a – in terms of estimation of the costs of war, that 5 percent number is huge. And of course, in an escalation scenario, you push well beyond that 5 percent point, up to upwards of 125,000 people. And so I think there’s a lot of drama in these numbers that you’ve put forward.

I want to ask Michelle to offer a few thoughts, and then we’ll come back to you, Francesco. Michelle, thank you.

Ms. Strucke: Thank you, again, for this incredibly important and sobering data. And a couple things I wanted to highlight as well that you said were this idea of – the idea of with an epidemic and without an epidemic, just given the crowded conditions in Rafah, with 1.3 million people that are crowded into a space that previously held 200,000, with the horrendous sanitation and water contamination conditions that we’ve now heard about on this broadcast for eight episodes, the risk of that epidemic, I think, can’t be overstated. This is the kind of thing that when I was in government was almost panic inducing, when we introduced into refugee situations things like measles, which are incredibly contagious.

I think our world has learned a lot about infectious disease from the COVID-19 pandemic. And from that, I think we should be able to understand that something that’s many times more contagious than COVID-19 being introduced into a population with crowding a lack of sanitation is really catastrophic. So I wanted to point that out because it’s not a light concern, and I certainly appreciate that you made that point in your data.

Another point I wanted to highlight was really two questions for you, which are, one, you know, kind of how did you consider in the malnutrition state, if you could at all, the effects on the population of doing things like – we’ve seen these reports of people eating animal feed that they grind into bread, or bird feed, or drinking contaminated water. I was curious sort of how that was in the data.

And the second question was, this data is so useful and you’ve – and you’ve been so – you know, importantly, have shared it. Can this data be used by humanitarians and governments to look at the potential impact of certain interventions on the health situation of the population? I ask that in particular because as we weigh policy decisions such as the U.S. government and others building a pier to allow more aid in or airdropping really quite small amounts of food into the Gaza Strip, are they able to use your data to understand kind of what a long-term impact might be? Is it really a drop in the bucket? And can they use your data to see that?

So those are my two questions. But thank you for this incredibly important contribution.

Dr. Morrison: Over to you, Francesco.

Prof. Checchi: Thank you. So I’ll perhaps address Michelle’s questions, if that’s OK.

The malnutrition analysis, so we looked at malnutrition as an underlying condition that is, you know, then a driver largely for infectious disease mortality. And I think viewers hopefully will appreciate that when a child presents in a hospital with severe emaciation, severe malnutrition, it’s usually because that child has got pneumonia or acute diarrhea, you know, some infectious condition that has – that is ultimately the final – the final, the direct cause of death. We haven’t really gone into great depth in terms of characterizing all of the different pathways that are sort of linking malnutrition with mortality via infectious diseases, via water and sanitation. It’s something we want to do for the next iteration of the – of the project.

It’s worth noting that we’ve been basically inventing methods as we went along. Nobody had really done this before. I don’t say that – I don’t say this to attract praise, but just to say that we have worked as fast as we could to produce these initial estimates and now we’re looking to refine some of our work.

But your – you know, for example, what one – one limitation of our nutritional analysis is that we looked at – we look at Gaza as a whole. But as you rightly sort of pointed out, Michelle, what is really happening, as we can see on TV, is that distributions are failing because people are – you know, are essentially going to the trucks, taking the food down, starting to eat on the truck. And by the time that convoy of food makes its way to the most remote areas, even assuming – and usually it does not happen – that it is allowed through, clearly, a lot of the equity has – you know, in distribution has not happened. So we’re going to be seeing pockets of particular deprivation, I would think, within the Gaza Strip.

In terms of how our data are being used, it’s early days. We have a parallel project, evaluation of actually how our findings will, in fact, impact policy and how they will be perceived. Clearly, some of our projections are useful to humanitarian actors to, for example, predicate decisions such as, well, if we had – if we even had a humanitarian pause of three weeks, should we – should we perhaps do a cholera vaccination campaign. That’s doable in three weeks; should we not prepare for that?

On the nutrition front, again, because it is very much a pressing issue, I think that what – we are actually trying to do an additional analysis this week that we will hopefully publish within a few days, for example to show that the amount of food that needs to go in in order to revert, or rather to avert any further worsening of the nutritional situation needs to be higher than the typical target, and that’s quite simply because you need to refeed. You need to replenish lost energy reserves. So we’re trying to quantify that.

One thing I think we will be able to show fairly compellingly is that even though the proposed sea route, the port that the U.S. is building off of Gaza, may be transformational when it comes online it in reality will likely be far too late to prevent a catastrophic escalation of famine.

And, you know, so it’s just examples that I’m giving, I suppose, of how you can use these data and these models to inform more granular decisions than just, you know, we need a ceasefire.

Dr. Morrison: Francesco, just listening to you one impression I have is that as you’ve thought about what we’re seeing unfold now in the worst parts of Gaza we may have underestimated the force of anarchy and disintegration of society.

If we cross a threshold into anarchy and disintegration that becomes its own escalatory driver of deterioration in health status. Is that a fair way of interpreting what we’re hearing from you?

Prof. Checchi: Generally, the evidence is that across different cultures social coping mechanisms deteriorate in crisis settings and particularly in very extreme scenarios such as what we’re seeing here.

So, yes, I think we have to factor that in as well. And it isn’t because Palestinians are unable to collaborate with each other. In fact, you know, Gaza is well-known for coming together and trying to cope with adverse circumstances, and God knows that they will have done everything that they can under the circumstances to help each other.

But, nevertheless, there comes a point where those social networks, those coping strategies, break down, as you’re saying, Steve, and then it becomes very difficult to operate for humanitarians as well. There is any an additional layer of insecurity, I suppose, that, you know, settles, I suppose.

Dr. Morrison: What has been the reception by major – by the leadership of major institutions, the major implementers and responders but also major governments that are involved like our own government here in Washington? What has been the reception that you’ve received from those who – decision makers that you’re trying to create a tool for decision makers?

Let’s take the major governments and then let’s take the major international institutions, government and nongovernment, and international like under the U.N. What’s been the reception so far?

Prof. Checchi: It’s a little bit too early to tell. So the report came out three weeks ago and we are – we have basically been in the process of briefing different stakeholders sometimes publicly, sometimes privately – governments, as you were pointing out, but also U.N. actors.

By and large, I think we’ve received appreciation for providing evidence where there was none, if you like, so that these kinds of decisions can actually be predicated on some real figures and not just on sort of empty principles, if you like.

But I think we’re still waiting to see, quite frankly, what impact these projections really will have. It’s possible that the slightly different approach that we’re seeing from the U.S. government and other important players over the last few days does in part reflect what we have published but at present I am not so sure that I can make that inference, as a conscientious scientist anyway.

Dr. Morrison: Yes. It’s very clear that you’ve gone out of your way to try and remain as objective as possible and steer clear of sort of political rhetoric in the way that you present all of this. And I think that’s quite important. I know Michelle would like to offer some additional thoughts. If you can tell us also, you know, what are the two or three topline messages that you want to impart to, let’s say, a Washington decision-making audience.

Michelle.

Ms. Strucke: I think that the timing of your work is extremely significant. We’ve said before, and many have said, that, you know, time equals lives in this conflict. You’ve demonstrated through this data that some projections of numbers behind which are real families. We’ve seen stories of, you know, parents that struggled with IVF for 10 years and then had babies who were killed in an instant in this conflict. So the finding that the majority of the deaths are coming from the act of combat is quite significant.

I think then the excess deaths caused by other health issues are really important to highlight as well for this audience, as a Washington audience is thinking about, you know, the fact that in the next few months when everyone working in this administration in the US is still in office – obviously, we don’t know what happens in November – these are real lives that they can have an impact on. So those numbers of, you know, at minimum 11,000, if a ceasefire decision is reached, it’s really significant to say that a ceasefire does not stop people dying. It doesn’t stop many of these children dying of malnutrition, or, you know, families with issues like you mentioned, heart disease and cancer, that will continue to die after a ceasefire is reached.

And even if not, and I think with the way the politics are going, the many struggles of reaching even a temporary ceasefire show that the higher numbers are probably more likely. And that is really terrifying, I think, to think that this many innocent people could be killed as a result of this conflict and through excess mortality. I think that I – certainly, it’s my hope that you’re asked for briefings by some of the senior leaders in the U.S. government. I think your information is extremely important for them to hear because they can look at one more thing to highlight, the nature of the deaths.

When you broke it down by sex and by age, we’ve had other guests on this broadcast in the past point out the fact that the very nature of something being described as indiscriminate in terms of attacks on civilians is when it’s identical to the exact population that’s in the Gaza Strip. And I think for our viewers, many, you know, extremely knowledgeable people, to understand that “indiscriminate” itself is a really important word in international humanitarian law. It’s the thing that says whether an attack is essentially legal or not.

And so the data that you have shared about the population distribution is quite important, I think, for people that are thinking about what the conduct of the war has looked like, and what that means for the conversation we had right before this, for potential red lines in U.S. policy. So I certainly hope that, you know, Congress is asking you for a briefing, and the White House, and others, because this is – these kinds of conclusions are the things, I think, that are needed – not just for operational humanitarian planning and health planning, but for really the consequences of policy actions or inactions that we’ve seen.

Dr. Morrison: Over to you, Francesco.

Prof. Checchi: Yeah. I mean, it’s clearly not our job as academics to drive decision making or apply political pressure. But I think one of the – one of the frustrations for me, or the problems that I see in this crisis, in this conflict, is that the rhetoric is very strong and positions are not really articulated beyond very elemental, very superficial arguments. Such as, you know, there is or a there isn’t a right for a country to defend itself. We are going to – we’re working on a humanitarian pause at some point, for some duration.

There is a – there has to be, alongside those statements, much more by way of harm-benefit assessments, by way of actually showing and appraising the different options, the alternatives, by way of really fleshing out the human impact that a decision can have. And that’s a burden that I think we all need to accept from humanitarian, to political, to military actors. That is not a burden that we can escape, quite frankly. And hopefully our work will create a bit of precedent for that to happen more systematically in other wars, in other crises elsewhere.

I think – Michelle, I think you have otherwise laid out sort of some of the main kind of concerns here. I would once again sort of want to lay the emphasis on the nutritional situation, if that’s possible, because, as I was mentioning, when we actually look at the pattern that we’re seeing in terms of the amount of food going in, it is probably worse than what we have assumed in our escalation scenario, in our most pessimistic scenario. We had seen that pattern getting better over time, from late October to about late December. But since then, the number of trucks being allowed in has really plateaued or oscillated. And basically, at this rate we’re heading for a catastrophic famine. Let’s be honest about this.

So there is a choice, as your other guest was laying out, for – there is a choice to allow more trucks in. You need probably on the order of 7(00)-900 kilocalories per day more going in. That can happen tomorrow. And what we are at least trying to do here is to say, OK, that’s your choice, and these are the consequences of taking or not taking that choice.

Dr. Morrison: Thank you, Francesco. We’ve reached the end of our – of our time here. Thank you for extending a few minutes beyond. I think it is important to get out on the table that the realistic assessment that we’re heading into a catastrophic famine. That has become a subject of much debate in recent days. And I think people are going to be looking at this very, very carefully.

You know, one thing that you’ve done that’s – is defy the pessimism or skepticism that you could do work of this kind under these circumstances. I mean, you’ve put together a very – you have admitted that there were difficulties in certain areas in terms of data. We all know that, and you’re very open and honest about the limitations, but nonetheless you defied the common wisdom that this type of work could not be done in these sort of circumstances. And so congratulations to you, and we look forward, certainly, to the next product. When will the next product come out, would you guess?

Prof. Checchi: We are hoping for next – for another sort of comprehensive update sometime in April. But before that time, I think there’s going to be a piece on the nutritional situation specifically.

Dr. Morrison: Do you have a date for that?

Prof. Checchi: We are working on it this week, so we might get something out by the end of the week. But it depends on, you know, kinks of the analysis, let’s say.

Dr. Morrison: OK. Thank you. Thank you so much. Again, congratulations. We’re all in your debt for the value of this – the great value of this work that you’re doing. We look forward to seeing the new work on nutrition and we’ll remain in close touch.

Michelle, any closing thoughts?

Ms. Strucke: Just my thanks as well. This is the kind of analysis that’s needed to understand, I think, the point we’re trying to make with this series, which is the human consequences. There are real people at stake and, as you said, choices being made today in rooms of people that don’t have to look into the faces of those they’re affecting. And it’s such an important decision-making tool to have this data. So, with everything going on right now, I certainly hope that this is a useful way to, on a macro scale, understand the magnitude of those choices.

Dr. Morrison: Thank you.

Thank you so much, Francesco.

Prof. Checchi: Thank you very much. I appreciate it.

 (END.)